This article originally appeared in the Summer 2022 issue of the Ontario Medical Review magazine.
Two sides commit in writing to moving forward on achieving gender pay equity for physicians
The next three years will be a pivotal period for Ontario’s 14,000 female physicians who have been waiting for decades for pay equity with their male colleagues.
When Ontario’s doctors and the Ministry of Health signed a new Physician Services Agreement in the spring, it was a historic moment. For the first time, the agreement committed the two sides in writing to take the necessary steps to achieve gender pay equity between female and male physicians in Ontario.
The written pledge was the first by any jurisdiction in Canada and comes after years of lobbying.
OMA past president Dr. Samantha Hill had mixed feelings when she learned of the commitment. “On the one hand, I’m elated that it’s being acknowledged and that it’s in writing and that it’s at official levels of bureaucratic care. But on the other hand, it’s fundamentally sad that it’s 2022 and we’re just now getting to the point where we’re trying to address it in a meaningful fashion.
Understand why female physicians earn less than their male counterparts
“With more and more physicians being female, having them systematically underpaid means that the medical system is systematically underpaid, and that means that patients suffer in the end.”
— Dr. Samantha Hill
”The gender pay gap issue was a priority during Dr. Hill’s 2020-21 term as OMA president, although the COVID-19 pandemic got in the way of progress that year.“Over half of our incoming medical students are female and over half of our doctors are female in a variety of specialties. And accepting that half of our population is underpaid, based on their gender, their sex does not sit comfortably with me."
But she said the issue is about more than fairness for female doctors, who make up about 43.2 per cent of Ontario’s physician workforce – a number that could reach 50 per cent by the end of this decade. Dr. Hill believes that accepting the status quo contributes to the demise of the medical system. “With more and more physicians being female, having them systematically underpaid means that the medical system is systematically underpaid, and that means that patients suffer in the end.”
The gender pay disparity in medicine is not an Ontario problem or a Canadian problem – it’s a worldwide issue. In the U.S., for instance, a 2021 survey by Medscape found that overall, male doctors earned 35 per cent more than female physicians. However, comparisons between studies are difficult, owing to the differences in data sources and methods employed.
Even though the fee-for-service model most widely used in Ontario is, on the face of it, gender-neutral, evidence of gender pay disparity is well established in the province.
Photo: Dr. Samantha Hill is a Toronto-based cardiac surgeon and operates at Sunnybrook Hospital and St. Michael’s Hospital. She says female medical students and residents continue to be discouraged from entering higher-paid, male-dominated specialties.
Disparities in Physician Compensation by Gender in Ontario, Canada, a 2021 study conducted by the OMA’s Economics, Research and Analytics team, gives the most complete picture of the gender pay gap in the Ontario medical system. After accounting for medical practice characteristics, region and specialty, the overall daily payment gap between Ontario’s male and female doctors was 13.5 per cent. The gap within some specialties was even higher. In cardiology, for instance, the adjusted daily pay gap between female cardiologists and males was 26.8 per cent. It was 37.6 per cent in neurosurgery.
The findings were based on an analysis of the daily OHIP billings of 31,481 physicians, which amounts to almost all practising physicians in Ontario with OHIP billings in the 2017-18 fiscal year.
While some nay-sayers don’t believe there is a gender pay gap, Jasmin Kantarevic believes the best current evidence strongly suggests that it does exist and across most medical specialties. As chief economist of the Economics, Research and Analytics group, it was Kantarevic’s team, led by Sharada Weir and Mitch Steffler, that provided evidence to the Ministry of Health and OMA negotiators who achieved the written commitment to address the issue.
“It’s a complex topic but we are quite confident that it’s a significant problem,” he said. There are many reasons for the pay inequity, but Kantarevic says two of them are critical and account for about two-thirds of the gap.
“Put women, particularly BIPOC (Black, Indigenous and people of colour) women on committees and in places where decisions are made … if you want change to occur.” — Dr. Clover Hemans
The first is that female physicians tend to be in specialties, such as family medicine, pediatrics, psychiatry and obstetrics and gynecology which are lower on the income relativity scale – the scale that compares how much doctors practising in different specialties earn. Male doctors tend to congregate in higher paid specialties.
But the gender pay gap exists even within specialties. Kantarevic said some recent research shows that in some specialties, for a fee code that pays the same, female physicians tend to spend more time on average with the patient than their male counterparts. And the current fee-for-service pay system does not generally take that extra time spent with patients into account (although there are some provisions to compensate for specific patient complexities).
Dr. Clover Hemans, co-chair of the OMA Women Committee and past president of the Federation of Medical Women of Canada, said some studies have shown that female family physicians, on average, spend about five minutes more per patient than male doctors. Dr. Hemans, a family physician who works in Oakville, said many female GPs take more time with patients and procedures because they emphasize building relationships over the number of procedures carried out each hour. Relationship-building is what makes family medicine so “enriching and sometimes really fulfilling on both sides, for both the patient and the physician.”
“But you’re not paid for that. You’re paid for the procedures.” Extra compensation for certain complexities doesn’t go far enough, she added.
Photo: Dr. Clover Hemans is an Oakville-based family physician and is co-chair of the OMA Women Committee. Dr. Hemans says one reason many female GPs earn less than their male counterparts is that they take more time with patients and emphasize building relationships.
Tackling these two major underlying causes won’t be easy. Under the ground-breaking commitment in the new PSA, the task of the bilateral Physician Payment Committee is to address fee disparity by accounting, among other things, for the time required to provide the service. In addition, the OMA and the Ministry of Health have committed to addressing income. Income disparity between specialties will be addressed by using the agreed-to Fee-Adjusted Income Relativity (FAIR) model developed by the OMA Relativity Advisory Committee. It seeks to achieve pay relativity, or fairness, between specialties as measured through hourly compensation adjusted by overhead and education.
“Essentially what it will do is that any new allocations will be reallocated to specialties that are relatively underpaid,” Kantarevic explained. “That means, by itself, that it will benefit female physicians.”
The Physician Payment Committee will also work to modernize the Schedule of Benefits, looking specifically at ways to address the gender pay gap. Committee members will begin the process by consulting with all OMA sections, asking them to identify areas where there are fee inequities.
The critical job of modernizing the fee schedule is “Herculean or actually Sisyphean,” Dr. Hill said. “No matter how much work you put into it, there would always be more to do.”
The fee schedule is huge, describing thousands upon thousands of medical procedures and specifying compensation for all of them. “It’s antiquated,” Dr. Hill said. “It has grown like an old hospital that just keeps having new things added to it, as opposed to being designed initially with the future in mind.”
The underlying question that needs to be asked is whether the fee-for-service system is the best way to pay most Ontario physicians, she added. The OMA’s 2021 gender compensation study suggested that alternate practice models, involving a hybrid of capitation and fee-for-service, may result in lower gender pay disparities.
One important provision is the new PSA opens the door for more family doctors to join Family Health Organizations, a successful hybrid model that many patients prefer. This should have the additional benefit of helping reduce the gender pay gap, Kantarevic said.
Clearly, the parties have a huge job ahead in modernizing the fee schedule and addressing fee and income relativity. The PSA commitment says the mutual goal of the OMA and government is that the work is completed in time for implementation under the next PSA.
Beyond that, there are broader questions to be answered. Why are female medical students – who now outnumber men – sometimes discouraged from entering higher-paid, male-dominated specialties? Many female physician leaders say this is still happening in medical schools and residency programs, just as it did when Dr. Hill was choosing a specialty more than 10 years ago. She remembers approaching a senior cardiac surgeon and asking him for a reference letter to apply for a cardiac residency. He told her she couldn’t go into cardiac surgery because she’d want to have a family someday and that would make it impossible.
“I told him, I guess we’ll have to agree to disagree on that one,” said Dr. Hill, who now operates at Sunnybrook Hospital and St. Michael’s Hospital and is affiliated with the University of Toronto.
Why is there so little recognition that female physicians – like women everywhere – typically bear more of the burden of child-rearing, household duties and elder care, according to Statistics Canada and other studies?
Dr. Hill suggested there could be daycare centres with longer hours in every hospital, which would at least help physicians who practise in that setting. “Because I can tell you, as a single mother of two children, (it’s hard) trying to figure out how to get my kids to school or daycare when I’m supposed to be at work for 7 o’clock or 6:30 or 6.”
Dr. Hemans asks why there are so few women in leadership positions in medical organizations, on boards, in hospitals, in academia and on hiring and residency boards? Garnering women and those from diversely inclusive backgrounds, onto hiring committees will change some of the discussions and perceptions of what great leaders might look like. These types of equity bound changes to hiring and promotion should be prioritized. This is one way to gain entry and a voice at the places where decisions are made.
“Put women, particularly BIPOC (Black, Indigenous and people of colour) women on committees and in places where decisions are made … if you want change to occur,” Dr. Hemans stressed.
She also emphasized the importance of encouraging male physicians to work hand-in-hand with their female colleagues to ensure that gender pay equity is a priority.
“How often do you win a war without allies?” she asked. “I don’t want this to be a war. I want it to be something that’s considered a wave or a change, where everyone gets an opportunity to be their best self.” And for female physicians, being their best selves starts with being fairly compensated.
“What we really need to do to bring more male allies on board on this issue is really having this discussion, having education and not make it a blame-based discussion.” — Dr. Simron Singh
One such ally is Dr. Simron Singh, a medical oncologist, wellness lead for the Department of Medicine at the University of Toronto and a member of the OMA Burnout Task Force. For Dr. Singh, eliminating the gender pay gap in medicine is simply a matter of equity.
“We all have to be working together to build a sustainable, equitable, fair system that works for all of us, both providers and patients.”
A recent OMA survey of physicians – one that had a very low response rate – found that only 34 per cent of male respondents agreed that a gender pay gap exists. Dr. Singh believes most male doctors with that attitude simply don’t understand the issue.
“What we really need to do to bring more male allies on board on this issue is really having this discussion, having education and not make it a blame-based discussion.”
Physician wellness and pay equity go hand-in-hand, added Dr. Singh. “I do think we have to work together to solve this issue so that we can improve the wellness of all of us and create a more sustainable health-care system, one that people want to be part of and are proud to be part of.”
Photo: Toronto-based medical oncologist Dr. Simron Singh, emphasizes the need to bring more male allies into the conversation around gender pay gap issues.
Keri Sweetman is an Edmonton-based writer.