Gender Inequity in the Clinical Setting

Abstract

Women in surgery continue to face inequitable treatment from surgical leadership, their peers, hospital staff, and even from their patients. Despite this, women surgeons continue to produce equal, or improved, clinical outcomes for their patients, with their work being given less remuneration than that of their male peers. The cultural stereotypes and biases that drive these inequities are implicit and subtle; however, they have dramatic effects on the lives and careers of women surgeons.

Introduction: Equity as the Road to Equality

Equality is the state of treating all people the same, regardless of situation or context. Equity, however, is tied deeply to the concept of justice. It is defined as a process of seeking long-term sustainable solutions, informed by thoughtful consideration of existing social and power structures, to address existing inequalities. This means supporting individuals in accordance with their unique contexts. It entails allocating resources in an unequal way for the goal of achieving more equal outcomes.

As with all power structures, our health care system and our surgical culture continue to produce inequities and inequalities across groups by rewarding certain demographics above others. This is increasingly implicit and subtle. Explicit discrimination and harassment of women has become far less common and less tolerated over time. Yet, disparities in the advance, compensation, and treatment of women surgeons persist.

If our goal is to fix these problems, we must first identify them. In this article, we examine what is known about gender inequities in the context of clinical relationships (with staff, other physicians, and with patients) and the data on the pervasive pay gap. Lastly, we will again discuss the concept of equity as well as the psychological and social impulses that continue to drive gender disparities—and the opportunities for equitable change.

The Role of Gender in Clinical Practice

Experiences of explicit bias have become far less common within clinical practice, likely because of larger cultural, legal, and institutional changes and policies. Yet, many studies show that surgical environments continue to be rife with implicit gender bias. ^{1 2 3 4} Moreover, experiences of gender discrimination come from surgical peers, patients, and staff. ^{1 2} Even in environments with a clear goal of gender equity, implicit biases persist. ⁵

Dr. A is a midcareer surgeon who receives a consultation for a patient with complex diverticulitis and plans a laparoscopic resection. In the operating room (OR), Dr. A encounters bleeding and needs to convert to an open surgery. Dr. A quickly directs the OR staff and anesthesia team, stops the bleeding, and stabilizes the patient. After the surgery, the patient recovers without further incident. Dr. A informs the referring physician of the complexity of the operation, the intraoperative complication, and the patient's outcome.

If Dr. A is a man, this event is unlikely to harm his career. The OR team has confidence that Dr. A knows how to handle an emergency and believes that he acted quickly and appropriately to take care of the patient. The referring physician will be unlikely to change referral patterns for Dr. A following the single event. This circumstance may even enhance his reputation as a talented surgeon who can handle complex cases and take good care of his patients.

If Dr. A is a woman, the scenario is likely to differ. Intraoperatively, the team—surprised by her rapid change in demeanor—finds Dr. A to be assertive and demanding. Following the surgery, the perception of Dr. A as difficult spreads through the OR staff and decreases the desirability of working with her in the OR. The referring physician is less likely to make ongoing referrals to Dr. A, believing her to be less skilled. This event may affect her reputation as an effective surgeon, hindering her ability to build a practice.

Relationships between Referring Physicians and Surgeons

While women surgeons achieve specialization training and practice in academic institutions in equal proportion to men, they have less specialized caseloads and practice in smaller networks with fewer available expertise-building cases. ⁶ Women surgeons perform fewer complex cases—but not because of training level, seniority, or familial obligations. ⁷ Surgeons are dependent on referring providers to build their practices. Based on several studies, surgeon gender plays a strong role in the determination of referral patterns.

One study found that, while men made up 77.5% of all surgeons, they received 87.1% of all referrals. ⁸ Women surgeons were more slightly likely to receive consults from gender-concordant physicians, and male surgeons were much more likely to receive referrals from a male clinician. Additionally, women patients were disproportionately referred to women clinicians and constituted 76% of all referrals to women surgeons.

Another study demonstrated that women surgeons receive, on average, five fewer referrals per month than their male counterparts, a number that accounts for 30% of new patient referrals. ⁹ Rather than improving over time, senior women surgeons received an average of 11 less referrals per month than their senior men counterparts. In addition to the discrepancy in number of referrals, the type of referrals differed; women surgeons were less likely to receive better-paying operative referrals than their male counterparts (25 vs 33%, p  < 0.001).

Furthermore, data show that referral patterns change for men versus women surgeons after an unexpectedly good or bad outcome. Heather Sarsons, in her PhD thesis, demonstrated that after an unexpected death, referrals to a woman surgeon dropped by 54%, whereas for a man there was only a small and temporary stagnation. ¹⁰ If a patient unexpectedly survived, referrals to men surgeons improved, whereas referrals to women surgeons did not. Additionally, the poor outcome of a female surgeon negatively affected the referrals not only to that surgeon, but also to her female colleagues. This indicates that physicians become more pessimistic about women surgeons' abilities after they endure a complication and remain less optimistic even after they experience a good outcome, whereas the inverse is true for men.

Given the existing payment structures and current common promotion criteria in academic surgery, unequal access to referrals undoubtedly harms women surgeons' career success and advancement. Surgeons are dependent on referrals to be productive. Moreover, the volume of referrals a physician makes to a given surgeon is a proxy for that physician's belief in the surgeon's ability, and the data illustrate clearly that women surgeons continue to suffer from negative bias from other clinicians.

The Surgeon–Staff Relationship

Gender inequity is not unique to the physician–surgeon relationship. Relationships with nurses, OR staff, and patients are also influenced by gender, with substantial implications for patient care and outcomes.

In a Canadian qualitative study based on interviews with OR team members, the authors found a highly gendered atmosphere. ¹¹ In the OR, collaboration and teamwork are essential to the care of the patient. This study found, however, that women surgeons face challenges that male surgeons do not. Challenges cited include harassment, bullying, and being perceived negatively by staff for displaying leadership behaviors. This created an environment the authors described as “conducive to breakdowns in communication and patient safety… in addition to diminishing team morale, psychological safety, and provider well-being.” Women surgeons reported that they felt a need to work harder to prove themselves to staff, and they expressed concerns that their needs for assistance during difficult cases were not taken seriously and that they received inferior scheduling and allocation of skilled staff to their operations. Moreover, these same observations were also identified by surgeons, nurses, OR techs, and anesthesiologists of both genders.

In one Norwegian study that utilized both semi-structured interviews and a nationwide survey, women physicians consistently reported that they were treated with less respect and received less assistance from nursing staff than their male colleagues. ¹² The interpretation by physicians was that this discordance was an attempt to reduce the status differential between women nurses and physicians. To overcome these differences, women physicians reported doing more for themselves without asking for assistance, and that they made a conscious effort to try to become friends with women nurses.

A questionnaire-based study in Quebec looked at physician–nurse knowledge sharing and complex decision-making, and the impact of gender on this type of collaboration. ¹³ The study found that physicians of any gender had a greater belief in their capacity to execute treatment of patients, as compared with nurses of either gender. However, male physicians had almost twice as much reported self-efficacy as women physicians. Being a woman physician appeared to have a negative impact on collaboration with nurses, whereas the impact was positive for men.

A recent mixed-methods study that utilized qualitative interview–based findings to build a quantitative survey of emergency room nurses and resident physicians found that gender had a significant impact on interprofessional interactions. ¹⁴ Although nurses expressed greater frustration with male residents, who they perceived to be more dismissive and less collaborative, female residents reported more frequent questioning of their clinical plans by nurses—especially by female nurses. While nurses may have perceived their interactions with female residents to reflect a greater collaborative ability, the female residents felt that such interactions reflected a decreased confidence in their abilities. Importantly, the authors note that power and privilege in the workplace hierarchy is not affected by gender alone—but also by sexuality, race, and other social identities. Moreover, respondents reported limited agency in their ability to address perceived bias of all kinds, whether experienced by themselves or another colleague.

A lack of agency in the face of perceived mistreatment causes chronic distress. Subtle discriminatory comments or actions communicate a demeaning or hostile message in a manner that can make it particularly difficult to call out or address them directly. A recent study attempted to delineate the impact of these experiences (termed “microaggressions”) on physician burnout. ¹⁵ The authors utilized a cross-sectional survey of a large cohort of surgeons and anesthesiologists to measure burnout and the respondent's experience of racial and/or sexist microaggressions in the workplace. Over 94% of women reported experiencing sexist microaggressions, including sexual objectification (44%), invalidating of the realities of women (33%), expectations of appearance (35%), and inferior treatment (48%). Additionally, 81% of racial/ethnic minority physician respondents reported experiencing racial/ethnic microaggressions. Under-represented minority physicians experienced both the highest prevalence and the greatest severity of microaggressions. The odds of burnout were approximately twice as high among those who experienced microaggressions, and the effect was slightly higher for those women with the compound experience of both sexist and racial/ethnic microaggressions.

Originally described by Professor Kimberlé Crenshaw in 1989, the data on intersectionality (understood as the differential attribution of biased beliefs to individuals belonging to multiple interconnected groups and social categorizations) are vast and tremendously important and will be discussed elsewhere in this journal issue. However, the under-representation of Black women in surgery deserves mention here. While the proportion of Black matriculants to medical school continues to rise ¹⁶ and the proportion of applications to surgical residency from Black women has increased from 2.2 to 3.5% since 2005, ¹⁷ no progress has been made over the past 15 years in retaining Black women in surgery. ¹⁸ Under-representation of Black women surgeons at every stage of training and career persists. Our discussion of gender inequities is intensely applicable and important to this group of women surgeons.

The Surgeon–Patient Relationship

Despite the impact of gender inequities and biases, data demonstrate that the quality of care provided by women surgeons is either equal or superior to that of men surgeons. Two landmark cohort studies of population-based data from Canada provide insight into the impact of sex discordance between surgeons and patients, as well as the operative skill of women surgeons. In one study, female patients were found to suffer worse outcomes than male patients when treated by male surgeons; however, male patients treated by female surgeons had no difference in outcomes (when compared with female patients treated by female surgeons). ¹⁹ In the other study, women surgeons were found to have a slightly lower 30-day mortality than men for patients undergoing elective surgery, despite matching for patient age, sex, comorbidity, and surgical procedure. ²⁰

Women physicians spend more time communicating with their patients. A meta-analysis of studies on this topic showed that women physicians spend 10% more time with their patients during office visits. ²¹ Much of this time is spent in active partnerships behaviors, motivational interviewing, and psychosocial counselling. While this time may help establish relationships, it is a burden not shared by their male colleagues and may significantly limit the number of patients that a female physician is able to see. Notably, these studies have shown that—despite the time spent communicating with patients—men and women surgeons take the same amount of time to perform common surgeries. ²²

There have been substantial advances in the opportunities for women in surgery. Women can now be surgeons, have opportunities for advancement and leadership, and can build a significant practice. Yet, the playing field for women in surgery is not the same as it is for men. At every step of the way, inequities in the profession alter the way women and men are seen—and, despite parity on paper, alter the way women can practice.

The Pay Gap and Explanatory Fallacies

Psychological research supports the theory that women who seek leadership positions are penalized because of implicit gender biases and stereotypes that prescribe “maternal” expectations of women to be more communal and less self-seeking (also known as less ambitious)—whereas the inverse is true for men. ^{23 24 25} Within surgery, the impact of these stereotypes is perhaps best elucidated in research studies on the pervasive and persistent gender pay gap, which show that women are penalized for their ambitions, whereas men are rewarded. ^{26 27}

Since 1979, the gender pay gap has been cut in half—with women in 2016 making 81% of men's wages for equal work, as compared with 62% in 1979. ²⁸ Despite this progress, women in surgery are still not compensated equally to men. Much of the available data are extrapolated from general surgery, not specific to colorectal surgery, and come from academic centers, rather than private practices. In addition, the data on intersectional pay inequities for minority women or nonbinary surgeons are sparse. This article will review data on pay inequity in surgery, along with some of the ways in which the inequity has been propagated.

Data clearly show that in surgery, men continue to make more than women. In general surgery, the average salary for a woman surgeon was $40,000 less than a man surgeon; in subspecialities such as colorectal surgery, the data demonstrated a $44,000 difference. ^{29 30} A recent study by the American Society of Colon and Rectal Surgeons (ASCRS) evaluated differences in pay among ASCRS fellows, but did not provide data on whether gender made a difference in pay among the 479 surveyed participants. ³¹ Over the course of a career, what may seem to be a small pay inequity is amplified. Data published in Health Affairs in 2021 demonstrated that there was approximately $2 million of adjusted pay difference between male and female surgeons over the life of their career, increasing to $2.5 million for surgical subspecialists. Importantly, this 25% discrepancy persisted despite adjustments for factors such as hours worked, specialty, and type of practice. ³²

There are many explanatory fallacies for this pay gap. One argument is that women are more likely to work part-time. The 2018 Medscape General Surgery Compensation report refuted this argument demonstrating that men and women in general surgery were equally likely to work part-time (8 vs 8%). ³³ Another hypothesis is that women prefer to take time to do other noncompensation generating activities, such as administration or education. However, data show that women have higher clinical FTE on average than their men counterparts. ⁷ Maternity leave is also believed to be a cause of the pay gap; however, a recent study found that women's productivity did not change following maternity leaves of absence. ³⁴

Another pervasive fallacy is the belief that relative value units (RVUs) are an objective measure of surgeons' work that levels the playing field. RVUs are the dominant form of reimbursement in a pay-for-service health care system. Different types of interactions or procedures are reimbursed based on the work expected for that interaction, which is measured in RVUs. A procedure generally pays more than an office visit, and complex procedures pay more than simple procedures. In theory, RVUs should be gender neutral and compensate purely based on work done; however, there are gender discrepancies and inequities in the allocation of RVUs.

One study found that, over a 20-year period, women earned 1.65 RVUs less per case than their male counterparts. ⁷ Over the course of a year, this accounted for approximately 1,200 less RVUs per woman surgeon. Experience and seniority only exacerbated the differences; the inequity in RVUs rose to 3.30 less per case for senior female versus male surgeons. This difference persisted even when accounting for subspecialty, seniority, calendar year, and race.

These are not the only data that show disparate RVUs based on gender. Data demonstrate that in addition to billing less RVUs, women are paid less per RVU than their male colleagues. While the differences were significant by gender, the differences were greatest by specialty, where male-dominated professions, such as neurosurgery and cardiac surgery, made substantially more than female-predominant specialties, resulting in 24% lower hourly operative earnings for women than men. ²² This trend of lesser compensation in women-heavy specialties—termed “feminization” of “pink collar” professions—is one potential reason that women make less than men.

Specialties such as breast surgery (64% women; mean salary $326,000) and obstetrics (54% women; mean salary $315,000) are not reimbursed nearly as well as male-dominated specialties such as orthopaedics (5% women; mean salary $443,000) or cardiac surgery (6% women; mean salary $471,000). ³⁵ In addition to being occupied by more women physicians, the patients are also more likely to be women. One example in colorectal surgery is the feminization of pelvic floor as this tends to be less operative. Reimbursements for a surgeon caring for pelvic floor disorders may be less than their more operative colleagues. In addition, the pay on the actual procedure may be discrepant. A laparoscopic rectopexy with sigmoid resection (CPT 45402) is coded almost identically to a laparoscopic sigmoidectomy (CPT 44204) at 26.51 RVUs vs 26.42 RVUs, which means that the extra time to do the rectopexy is not reimbursed. ³⁶ This discrepancy is even more apparent in other specialties and may be best demonstrated by the example that a scrotal biopsy pays 123% of what is paid for a vulvar biopsy. ³⁷

Academic advancement of women is covered elsewhere in this issue; however, differential advancement is an important source of pay inequity. In the 2018 ASCRS compensation survey, there was a $50,000 pay difference between assistant and associate professor, and almost $100,000 between associate and professor. ³¹ The number of women who advance in academics is concerning. While 25.5% of all academic surgeons are women, and a similar number are assistant professors, these numbers progressively drop when we look at associate professors (18.6%), full professors (9.7%), and chairpersons (2.9%). ³⁸

Failure of advancement, referral issues, and decreased compensation all contribute to the pay disparity. Additionally, women may be more likely to take uncompensated jobs. The University of Alabama made a concerted effort to improve pay equity throughout the department. Prior to the initiative, there was a salary pay gap (56% male vs 26% female) despite no significant difference in RVUs. After attempts to remove the pay inequities, they were still unable to account for 30% of the discrepancy. ³⁹ Interestingly, another study found that leadership positions held by women were less likely to be paid equivalently for men and women, and this was in part responsible for 30% difference in the salaries of women surgeons. ⁴⁰ Attempts have been made to quantify nonclinical work, with educational RVUs or research RVUs; however, there is no national standard.

Partnership with industry can be an additional source of financial revenue, and sometimes incredibly lucrative. However, women are less likely to profit from these relationships. In a recent study, the authors found that 96.9% of the top 5 highest earners across medical supply companies were male. ⁴¹ Top female physician consultants were paid a mean of $41,320, while their male counterparts were paid $1,225,377 annually. Male gender was associated with higher payment even when adjusting for rank, h index, and specialty. Between 2013 and 2019, during the study, the payment gap only continued to increase. ⁴¹

Building Gender Equity: One Size Does Not Fit All

Implicit bias, social/cultural expectations, and pay inequity in the field of surgery—and their disparate impact on women—are well described in the literature. ^{38 42 43 44} But what does an equitable system look like? We propose a process of deliberate and systematic examination of implicit biases and education-based interventions to engender greater awareness of the human tendency to gravitate toward people like themselves and to form biases against those with whom they differ. Without clear-cut tools and systems designed to promote equity and inclusion, this impulse is likely to continue to drive disparities in medicine for women and all other under-represented groups.

Psychology studies have shown that people react quite differently to the subtle assertion of a stereotype (i.e., implicit bias), as compared with the explicit assertion of one. ²³ People tend to pursue tasks that are positively associated with their own gender stereotype and avoid tasks that are negatively associated with it. ^{45 46} Moreover, stereotypes can influence our behavior without any reminder of them and without our conscious knowledge of their impact. ^{47 48} When a stereotype is implicitly activated—such as when a “microaggression” is made—this impacts an individual's expectation about their own ability and affects their behavior. They tend to assimilate that bias and experience self-doubt. ^{49 50} However, when a stereotype is openly discussed, people who experience explicit bias tend to react against it, in an effort to defy it. ^{51 52}

Examining and combating implicit biases is a universal project. This is a human problem, not just a medical profession or surgery problem. Yet, there are special considerations for surgeons. There are specific opportunities for equitable action in academic surgery. Administration and surgical department leadership needs to ensure equal sponsorship for women and men physicians to join larger practices and to take on expertise-building caseloads; institutions and physician networks should revisit and assess their referral patterns to evaluate for equitable or inequitable patterns, and to intervene where necessary. Academic centers should commit to true pay equity and transparency.

The common argument that gender inequity is a problem that will fix itself as more women enter the field seems to absolve its proponents of responsibility. This pipeline argument is also, simply put, incorrect. ⁴² In medicine, where progress toward gender parity has been particularly slow, women medical school matriculants now outnumber men as of 2017. ¹⁶ Yet, in obstetrics and gynecology, for example, women have outnumbered men in practice since 2012, and major disparities in pay and leadership persist. ⁵³ Thus, achieving gender parity will require more than having an equal number of men and women in the field. It requires a close examination of persistent and pernicious gender bias and deliberate interventions to overcome these barriers to women surgeon's achievement.

Conclusion

Gender inequity continues within the field of surgery. Although the number of women surgeons is increasing, the obstacles they face in clinical medicine remain. Women surgeons must navigate more complicated relationships in building referral patterns, working with hospital staff, and in patient interactions. Additionally, the pay gap persists in terms of RVUs earned, payment per RVU, and total compensation. Until we find ways to even this playing field, we will not achieve equity.