Gender bias skewing surgeon referrals

Have you heard the surgeon riddle? It goes like this:

A father and son are in a car crash and are rushed to the closest hospital. The father is fatally injured and dies. The son is rushed to the operating room and is examined by the surgeon who says “I can’t operate on this boy. He is my son.” How is this possible?

Perhaps the boy has two fathers? Perhaps the boy was adopted and the surgeon is his stepfather? Perhaps the father wasn’t really dead? Perhaps the surgeon is the ghost of the boy’s father?

Or perhaps the surgeon is a woman and the mother of the boy.

It seems obvious when you know the answer, but actually in an experiment conducted in Boston with 300 students, only 14 per cent of university students and 15 per cent of children attending summer camp guessed the correct response. The participants were more likely to guess the boy was adopted.

That was in 2014 when one in every four surgeons in the United states was a woman. Even now, when most people think of a surgeon, they don’t picture a woman.

In many countries including Australia, women now make up the majority of graduating medical students. In Canada, medical school classes have been majority female since 1995. That’s over 25 years ago, yet today less than 30 per cent of surgeons in Canada are women and almost half practice in a single specialty – Obstetrics and Gynaecology.

Female medical students are still actively discouraged from pursuing surgical careers, and are more likely to drop out of surgical training.

Although the patient outcomes of women surgeons are at least as good as those of their male counterparts, in practice women experience a lack of mentorship and career progress into leadership, biased treatment in their everyday work environment, and one of the largest gender pay gaps in medicine in many countries including Australia.

In a recent study we evaluated pay per hour in the operating rooms for surgeons in Ontario and found that women received 24 per cent less per hour spent operating.

This is important because factors like choosing part time work or working fewer hours – factors commonly thought to account for the gender pay gap in surgery – shouldn’t influence hourly remuneration. In general, women performed operations that paid less even when we adjusted for speciality.

How does this happen?

In many jurisdictions surgeons rely on referrals from other doctors – patients with conditions possibly needing surgery are assessed by their GP or specialist and referred on to a surgeon for further consideration. The referring physician often has a lot of discretion when choosing a surgeon to send a patient.

In an ideal world, referrals should be based on factors that would affect timely access to high quality care, like surgeon experience, capability, availability, previous patient experience, and so on. Unless requested by a patient, a surgeon’s gender shouldn’t be a consideration. But of course we don’t practice in an ideal world.

Women surgeons have been found to receive fewer referrals than similarly experienced male colleagues and anecdotally many women find building a practice challenging. But despite the importance of referrals to the work of surgeons, little research has been conducted evaluating factors that influence referrals.

Our study published in JAMA Surgery addresses this knowledge gap. We used healthcare data from the province of Ontario, Canada from 1997-2016 to explore if the gender of a surgeon influences referrals.

We compared the proportion of referrals made by male and female physicians to male and female surgeons using a dataset of nearly 40 million referrals and 5,660 surgeons.

Although male surgeons accounted for 77.5 per cent of all surgeons, they received 79 per cent of referrals sent by female physicians and 87 per cent of referrals sent by other male physicians.

We found that female physicians were slightly (1.6 per cent) more likely to refer patients to a female surgeon, however male physicians were much more likely (32 per cent) to refer patients to a male surgeon.

The differences were greatest in surgical specialties with the highest representation of female surgeons, like gynecology and plastic surgery.

Sadly, as more women entered surgery over the study’s 20-year span, the referral bias didn’t decrease.

Although the study was conducted in Ontario, there is little reason to anticipate that gender bias in referrals doesn’t affect women in surgery worldwide.

The implications of gender bias in referrals in terms of livelihood and quality of career for women in surgery are clear. Woman surgeons need to work harder to build and maintain a practice and ultimately are paid less to do so.

However, the “old boys club” affecting referrals also has an impact on patients and the health system. Ensuring equitable and timely access to surgery is a challenge in many jurisdictions, so underutilising women in surgery because of gender bias means that patients wait longer for their care – a particularly important consideration as health care systems recover from reductions in surgical services due to COVID-19.

Our findings demonstrate the need for new efforts directly focused on eliminating gender bias within medicine.

Innovative changes are possible. For example, adopting a single-entry pooled referral model where referrals are scheduled to be seen by the first surgeon available would distribute referrals more fairly.

Change in some form is urgently needed – allowing women in surgery to continue to experience the impact of gender bias is inherently unfair. And underutilising women in surgery – by making patients wait so a doctor can refer them to his mate – is simply unacceptable.

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