A recent paper found that men physicians in Ontario display preferences for men surgeons when making referrals. The study was conducted by Dr. Fahima Dossa, a general surgery resident at U of T, under the supervision of Dr. Nancy Baxter, a surgeon at St. Michael’s hospital.

After analyzing over 40 million referrals made to surgeons in Ontario between 1997–2016, Fossa found that, 32 per cent of the time, men physicians have the tendency to make same-sex referrals. Women physicians only make same-sex referrals 1.6 per cent of the time. 

It was previously thought that the gender wage gap in medicine was partially perpetuated by women choosing lower-paid specialties because of lifestyle choices. Dossa’s results defy that belief by showing that active bias against women surgeons exists even in Ontario’s fee-for-service system.

A persistent gender pay gap

Gender-based wage gaps in medicine are well-recorded in Canada and other countries. Despite a significant increase in the number of women physicians, the gender wage gap persists and, in some cases, is expected to widen over time. A study from the United States found that men physicians earned 16.3 per cent more than their women counterparts between 1996 and 2000. This disparity jumped to 25.3 per cent from 2006–2010. 

In Canada, the number of women physicians has risen exponentially in the last 50 years. Women now make up 40.6 per cent of all physicians, with 54 per cent under the age of 40. Similarly, the majority of medical students in most schools are women.

Despite improvements in representation, there continues to be a wage gap between men and women physicians in Ontario, even after adjusting for factors such as geography and specialties. Excuses for this disparity include ‘hidden curricula’ in medical schools that discourages women from choosing lucrative specialties like surgery, and the fact that women work fewer hours than men within those specialties. However, this disparity in earnings persists even when women are in the same fields as men and working the same hours, because of the structural bias in medicine.

Ontario’s fee-for-service system

Dossa believes that there are other factors at play here. In 2019, she published a paper stating that even though Ontario operates on a fee-for-service system, women surgeons still earn 24 per cent less than men surgeons on an hourly basis.

In that paper, Dossa found that women surgeons receive fewer opportunities to perform more lucrative procedures than men surgeons, a fact that intrigued her. “As procedures become more lucrative, you see fewer and fewer female surgeons performing those procedures.” said Dossa in an interview with The Varsity. “I don’t think that that’s a coincidence. I don’t think that women in surgery specifically decide that they are going to do the procedures that pay the least amount of money,” she explained.

Considering that patients require referrals to see specialists in Ontario, Dossa saw the potential for bias against women surgeons in that process and set out to investigate it. Her study found that, after adjusting for patients’ and surgeons’ characteristics, the gender of the referring physician played a strong role in the number of referrals a surgeon receives. Although men surgeons account for 77.5 per cent of the total number of surgeons in the province, they received 87.1 per cent of referrals from men physicians and 79.3 per cent from women physicians.

The data revealed that all physicians, irrespective of their gender identity, refer more people to men surgeons. However, men physicians display much greater bias than their women counterparts. This bias was most apparent in specialties with more women surgeons and does not taper off over time, according to Fossa’s calculations. This implies that increasing representation of women might not be enough to reduce the gendered wage gap in surgery.

Fossa found this fact particularly alarming. “Not only is [an increase in] representation not enough to fix the problem, we actually have a signal that [it] would create a representation of women where the problem may actually worsen,” she said. She still thinks that it is important to encourage more women to enter the field of surgery, but a more lasting solution would be to change the referral process altogether.

The referral process needs change

Fossa proposes a centralized system where a referral is forwarded to a group of surgeons instead of a particular individual. Patients can then be assigned to the surgeon with the earliest availability, effectively removing any bias that a referring physician might have against women surgeons.

This would not only provide women surgeons with more opportunities, it would also improve patients’ care. Because of the COVID-19 pandemic, there is “a huge backlog of surgical procedures that have been delayed because of our healthcare system being overwhelmed,” Fossa said. She noted that, if many physicians are referring patients to the same few men surgeons, many capable and available women surgeons will end up being underutilized.

While her work is the first to look at referral bias in medicine, Fossa believes that we are past the stage of data generation. “Although data is helpful, I think the next step — at least for me — is to translate this into policy change. How can we use the data that we’ve generated to actually fix the problem?”