Sex-Based Disparities in the Hourly Earnings of Surgeons in the Fee-for-Service System in Ontario, Canada

Abstract

Importance: Sex-based income disparities are well documented in medicine and most pronounced in surgery. These disparities are commonly attributed to differences in hours worked. One proposed solution to close the earnings gap is a fee-for-service payment system, which is theoretically free of bias. However, it is unclear whether a sex-based earnings gap persists in a fee-for-service system when earnings are measured on the basis of hours worked.

Objective: To determine whether male and female surgeons have similar earnings for each hour spent operating in a fee-for-service system.

Design, setting, and participants: This cross-sectional, population-based study used administrative databases from a fee-for-service, single-payer health system in Ontario, Canada. Surgeons who submitted claims for surgical procedures performed between January 1, 2014, and December 31, 2016, were included. Data analysis took place from February 2018 to December 2018.

Exposures: Surgeon sex.

Main outcomes and measures: This study compared earnings per hour spent operating between male and female surgeons and earnings stratified by surgical specialty in a matched analysis. We explored factors potentially associated with earnings disparities, including differences in procedure duration and type between male and female surgeons and hourly earnings for procedures performed primarily on male vs female patients.

Results: We identified 1 508 471 surgical procedures claimed by 3275 surgeons. Female surgeons had practiced fewer years than male surgeons (median [interquartile range], 8.4 [2.9-16.6] vs 14.7 [5.9-25.7] years; P < .001), and the largest proportion of female surgeons practiced gynecology (400 of 819 female surgeons [48.8%]). Hourly earnings for female surgeons were 24% lower than for male surgeons (relative rate, 0.76 [95% CI, 0.74-0.79]; P < .001). This disparity persisted after adjusting for specialty and in matched analysis stratified by specialty, with the largest mean differences in cardiothoracic surgery (in US dollars: $59.64/hour) and orthopedic surgery ($55.45/hour). There were no differences in time taken by male and female surgeons to perform common procedures; however, female surgeons more commonly performed procedures with the lowest hourly earnings.

Conclusions and relevance: Even within a fee-for-service system, male and female surgeons do not have equal earnings for equal hours spent working, suggesting that the opportunity to perform the most lucrative surgical procedures is greater for men than women. These findings call for a comprehensive analysis of drivers of sex-based earning disparities, including referral patterns, and highlight the need for systems-level solutions.

Figure 1.. Distributions of Earnings per Hour in the Unmatched Cohort

Specialties in all but A and B were chosen based on a count of more than 50 female surgeons in that specialty. Monetary values are rounded to the nearest US dollar.

Figure 2.. Mean Differences in Hourly Earnings Between Matched Male and Female Surgeons Within Each Specialty

The vertical dotted line represents mean hourly earnings difference between matched male and female surgeons ($25.98 per hour). Square boxes represent mean values; horizontal bars represent 95% CIs.

Figure 3.. Proportion of Operations Performed by Female Surgeons for the 200 Most Common Procedures Across All Specialties

Procedures are grouped into quintiles based on mean hourly earnings per procedure among male surgeons and ordered from lowest to highest earnings per hour. As hourly earnings increase, the proportion of females performing these procedures decreases. Monetary values are rounded to the nearest US dollar.