TORONTO, Ontario (CTV Network) — Female surgeons in Canada have long faced gender-based referral biases that result in large pay gaps, and an inequitable and inefficient environment for patients, Canadian surgeons say, but with the urgency surrounding surgical backlogs due to the COVID-19 pandemic, some say the time is ripe for major changes to healthcare.
In interviews with five surgeons and conversations with others who declined to participate in the story, CTVNews.ca heard their experiences and views on the inequity and problems within medical care, as well as a solution many believe could be effective in mitigating wait times and backlogs.
For Dr. Fahima Dossa, a general surgery resident with the University of Toronto, it started early in her medical training.
“Women, first of all, are being discouraged from entering surgery to begin with,” Dossa, who is also a PhD candidate with the school’s Institute of Health Policy, Management and Evaluation, told CTVNews.ca.
“Even once you make the decision to get into surgery, you are nudged or sometimes very much pushed into certain areas that may not be as remunerative. And I don’t think that that’s a coincidence.”
When Dr. Samantha Hill, president of the Ontario Medical Association first considered going into cardiac surgery, she was told “flat out” that she could not because “[she] was female and … was going to want to have children.”
“I was speechless because I couldn’t believe he would say it out loud,” she said.
For surgeons, these issues are not new, but they are rarely part of any mainstream or public conversation on health care and its impact on patient care.
A 2019 study published by Dossa and Dr. Nancy Baxter in the peer-reviewed medical journal JAMA Surgery already demonstrated that female surgeons in Ontario were paid 24 per cent less per hour of operating time than their male counterparts. Dossa and Baxter examined more than 1.5 million surgical procedures performed by 3,275 Ontario surgeons and made sure variables that were often used to explain away gender disparities were accounted for. A separate study that examines referral biases via 20 years of Ontario data and quantifies the magnitude of the biases just wrapped and could be published later this year, Dossa added.
Research has also shown that female surgeons are just as capable as their male counterparts, dispelling myths that male surgeons are somehow more skilled, with one study suggesting patients treated by female surgeons had a small “but statistically significant decrease in 30-day mortality.”
“No matter what evidence we produce, somebody always has some reason that it’s wrong,” says Baxter, a colorectal surgeon at St. Michael’s Hospital and a professor of surgery at the University of Toronto. She has published numerous papers as a scientist, but says research on these types of issues are always much more difficult to publish and come under far greater scrutiny during peer-review.
“This system actually discourages us from learning more about the biases within the system — actively discourages it,” Baxter said, stressing that it is not just a gender issue.
A February podcast by the Journal of the American Medical Association (JAMA), for example, came under fire after a since-deleted tweet promoting the episode asked, “No physician is racist, so how can there be structural racism in health care?”
HOW REFERRAL BIASES HAPPEN To be clear, the surgeons interviewed all say the biases and other inequities are not only gender-based, but extend to other groups like practitioners of colour, LGBTQ2S+, and new graduates. They also recognize the issues are not unique to their field, but rather the product of systemic and structural problems pervasive across any number of industries and is a reflection of wider societal prejudices.
“The gaslighting that happens to women — it happens to people of colour as well. So because you can’t put your finger on the racism and the sexism it’s really hard to counter it, especially with the people who just refuse to believe it exists,” said Baxter.
As Hill and Dossa also demonstrated, the biases begin in medical school and continue throughout a surgeon’s career — they come from colleagues, mentors, and patients, both old and young. While the issues are constantly being discussed in medical circles, problems raised a decade earlier, for example, remain endemic and unresolved even as more women enter medicine and surgery, surgeons say.
“Women now make up more than half of most medical schools. They don’t show up to that degree in all the specialties, and part of that is about things that happen in medical school that sway people one way or the other,” said Hill.
She believes some of the mentors who caution women are coming from a “good place”, having seen what the obstacles are, but that it is still based on an intrinsic bias around having children and caregiving needs that must be challenged.
Medicine is entering a different era, she adds, where much more time is spent counselling and establishing relationships.
“That currently isn’t valued monetarily the same way as procedural things are, so that needs to be addressed,” said Hill, noting that women are encouraged to enter fields that value relationships while men are encouraged to go into fields that value procedure.
“It’s what we call the hidden curriculum of medical school, and it’s about all the things that we don’t say that affect what you learn.”
It continues into their surgical careers through the number and quality of referrals they receive.
“Female surgeons receive much lower quality of referrals, and the referrals that they do receive are less likely to lead to operations being needed or recommended,” said Dr. Lesley Barron via email from Australia, adding that female surgeons are more likely than men to trial non-operative management of certain conditions too. Barron used to be a general surgeon in Ontario but said she moved away due in large part to Canada’s inequitable system.
“When female surgeons do take patients to the O.R., they are often referred to cases that are less lucrative than male surgeons.”
Hill says the OMA for its part, has pushed recommendations that include greater representation of female physicians in medical leadership positions, working towards greater pay equity across specialties, and advocating for standard parental leave regardless of gender. The latter is meant to normalize men taking leave to the same degree as women, so that the idea of having children becomes less of a career-limiting step, Hill said. But she acknowledged these are long-standing issues and that more action is needed more quickly.
Baxter and Dossa also endorse providing an environment where there is transparency around the kind of patients surgeons are being referred to and how much they are making.
But the biases are not contained just between colleagues, surgeons say, adding that patients both contribute to and are impacted by them as well.
Surgeons told CTVNews.ca they had experienced being explicitly told by doctors that a patient was not referred to them because they were a woman, or were told later that a patient did not wish to proceed after a consultation because they did not want a female surgeon performing the operation. Patients have also assumed that male medical trainees were the primary doctors, rather than the female physicians leading them — sometimes even after they’ve performed the surgery.
“It’s true that oftentimes to be seen on par as our male colleagues we need to be twice as nice and twice as good,” Hill said.
WAITLISTS AND BACKLOGS When the pandemic hit over a year ago, hundreds of thousands of surgeries, procedures and specialist consultations were postponed across Canada during the first few months to ensure hospital resources were readily available for COVID-19-related needs. Concerns over the backlog, especially for life-saving procedures, have mounted among doctors and patient advocates, even as some provinces have worked to clear the backlog.
Some surgeons say at least some of the waitlist issues are a result of referral biases.
“There are plenty of empty and short waiting lists of surgeons in Canada, both to see and operate on cases, but because the health-care system is so disorganized and inequitable, there is no way of transferring between surgeons who have short wait lists, and those who do not,” Barron said.
“This system leads to a large number of (mostly) female surgeons with short to non-existent waiting lists for O.R. time and their skills not being used.”
Compounding the problem, there is no way for referring doctors to know what the wait times are for individual doctors, surgeons say. In Ontario, for example, there is an information system portal that looks at wait times by hospital and by procedure, but Dr. David Urbach, Chief of Surgery and Director of Perioperative Services at Women’s College Hospital, says that information is not meaningful as it averages out those wait times. One surgeon might have a wait time of three months while another surgeon at the same hospital for the same procedure might have a wait time of a year.
“There’s also the issue about inequity or misallocation of patient demand and supply, which causes variation in wait times. So that right now some people are waiting three weeks to have elective surgery and some people are waiting two and a half years for the exact same operation in a hospital a few blocks away from each other,” Urbach explained.
“Everything I’ve said about surgeons translates tenfold to patients. So patients who are of a lower socioeconomic class, patients who are people of colour, recent immigrants, non-native language speakers, also end up with higher wait times and less access.”
Still, not everyone is convinced there is enough information to say more gender equity will specifically help improve backlogs in surgery.
To get a clearer picture, data on where the backlog is highest and where the gender gaps in referrals are highest would need to be examined to see if they match up, Hill says, adding that it is not a simple fix.
“As a cardiac surgeon, when I’m operating, there’s an anesthetist, but there’s also nurses and a perfusionist and a variety of support workers who help move patients around and then clean the room, those kinds of things. And so it’s not just a question of my time, but the entire team having time,” says Hill.
A SOLUTION THAT WORKS? Much of the focus around addressing backlogs involves adding resources and capacity to the health-care system, but surgeons say that does not address biases and inefficiencies and that proposed solutions to help address some of the inequities are met with resistance by many in leadership positions.
“When people say we need to spend money on extra O.R. time to shorten this list, it makes me really angry,” Barron said.
“What we need is for referrals and O.R. wait lists to be centralized and distributed to the locally available surgeons in an equitable way and for O.R. time to not go to waste.”
Most of the surgeons who spoke with CTVNews.ca advocated for some kind of single-entry referral model. The model would of course take into consideration the urgency of a patient’s medical condition. The set up would not cost a lot of money, according to Urbach, and would be the simplest solution health care leaders could do to simultaneously address the problem of backlogs and wait times, as well as the discrimination women surgeons face.
It is an equalizer and allows everybody to wait the shortest amount of time possible, said Urbach, who wrote about the model in a piece published in the CMAJ in 2020. The articled urged surgeons, hospital leaders and public policy makers to adopt a single-entry and team-based care model as part of the COVID-19 recovery plan, calling it an efficient, fair and ethical way to address a “once-in-a-generation opportunity” to create transformational change within Canada’s surgical services.
“Is there a push? Yeah, there’s lots of pushes. But it’s typically not being pushed by the people who are influential who can actually bring them into practice because there’s a lot of resistance amongst some surgeons and some surgeon leaders around adopting these models,” Urbach said.
“People who are successful in any model don’t have a huge interest in changing it, even if it means making it more fair for their women colleagues, … surgeons who are people of colour, early career surgeons.”
He is not alone in this criticism.
“There’s always going to be an excuse,” said Baxter. “When you have privilege, you’re not really going to be looking for ways to lose your privilege.”
Hospitals can be a source of equity, but also an incredible force of inequity, she added.
“How we encourage hospitals to actually deal with inequities within their system is pretty critical and a human rights issue.”
Despite the resistance for more widespread adoption, there are examples in Canada and elsewhere where single-entry, team-based models have been implemented successfully. In the U.S., some hospitals including top organizations like the Mayo and Cleveland clinics operate this way, Urbach notes. The Ontario Bariatric Network also uses this model for patients requiring bariatric surgery.
As head of the surgical department at Women’s College Hospital, Urbach is currently implementing this model for anorectal surgeries, where waitlists for procedures involving hemorrhoids and anal fissures are typically long. The program is set to launch at the beginning of April.
Even with these examples, there is also unease around losing patient autonomy in choosing their care provider.
“That’s obviously concerning because part of what we value about our physicians is their judgment to know when to operate and on whom to operate,” said Hill.
Advocates for the change say there is research that suggests patients would still prefer a shorter wait time over choosing their surgeon.
“They just have confidence that their quality of care is very good, which is what a lot of these team-based models can do because they are very transparent and they follow standardized care,” Urbach said.
“But there’s no groundswell of patient advocacy insisting on this.”
Patients worry about getting a “bad” surgeon, but Urbach says there are checks and balances in place to ensure rigorous standards are met. And the reality is, he adds, the type of data that would genuinely inform a patient on who is providing the best quality of care — such as surgical outcomes — is “very, very difficult to get and even referring doctors don’t really know.”
Whether change is possible remains to be seen, surgeons say. Individual hospitals can implement a single-entry referral model within their own network, but any system-wide overhaul would need to come from provincial governments, they explain, and simply throwing more money into health care is not enough of a solution.
“When you have a diverse workforce, patients do better,” Hill said.
“You ask different questions and research, you approach things with a different lens from a community perspective, and so the absence of any given group, whether it’s women, or a specific racialized community, or LGBTQ, means that we are weakening our capacity to provide care for patients.”