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Original Investigation
October 2, 2019

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

Author Affiliations
  • 1Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
  • 2Department of Surgery, St Michael’s Hospital, Toronto, Ontario, Canada
  • 3Institute of Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
  • 4Division of Minimally Invasive Gynecologic Surgery, University of Toronto, Toronto, Ontario, Canada
  • 5Department of Obstetrics and Gynecology, St Michael’s Hospital, Toronto, Ontario, Canada
  • 6ICES, Toronto, Ontario, Canada
  • 7Department of Surgery, University Health Network, Toronto, Ontario, Canada
  • 8Department of Epidemiology and Biostatistics, University Health Network, University of Toronto, Toronto, Ontario, Canada
  • 9Department of Medicine, University of Toronto, Toronto, Ontario, Canada
  • 10Department of Medicine, Mount Sinai Hospital, University Health Network, Toronto, Ontario, Canada
JAMA Surg. Published online October 2, 2019. doi:https://doi.org/10.1001/jamasurg.2019.3769
Key Points

Question  Do male and female surgeons in Ontario, Canada, have equal earnings for each hour they spend operating in a fee-for-service system?

Findings  In this cross-sectional study of 3275 surgeons, female surgeons earned 24% less per hour spent operating than male surgeons did and more commonly performed the least remunerative surgical procedures. In some specialties, earnings differences were more than $53 ($70 Canadian) per hour.

Meaning  Previous studies have attributed a portion of the sex-based earnings gap to differences in hours worked; however, this study demonstrates that even when equal hours are worked, female surgeons earn less than male surgeons and have fewer opportunities to perform the most lucrative surgical procedures.

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.

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