Solutions to the Gender Pay Gap in Canadian Medicine

As a member of the Equity in Medicine team, I volunteered to discuss the gender pay gap in Canada for an online hour long session on a weekday evening in early July. I thought the attendance in the summer would be around a dozen people if we were lucky. The response was incredible, enough to make me hope (faintly) that women physicians in this country may finally have had enough of being treated so unfairly when it comes to remuneration and angry enough to push hard for justified change. Since remuneration ($) is how we assign value to work in our society, I think it is well past time that the work of female physicians stops being both systematically and structurally undervalued. I barely scratched the surface of the topic in the hour, and one of the main feedback comments was that the session was not long enough(!). The goal was to start a long overdue conversation where women start standing up for themselves and each other and on that item, I think mission accomplished.

The other feedback point was people wanted to hear about solutions to the gender pay gap. Concrete, actionable items that can happen to close the gender pay gap and those are some (I have lots more) of what I will propose here. I’m a surgeon and I like fixable problems. PTMAs (Provincial and territorial medical associations- OMA,AMA, Doctors of BC etc) are the ones mostly in charge of negotiating physician remuneration with different provincial governments and so most of the solutions will focus on them, since they bear the lions share of responsibility for allowing this issue to go continue unchecked and in fact worsen over time. However, hospitals, provincial governments,academic institutions and medical schools also share responsibility for both ignoring and contributing to this problem. So here are a few items that would go a long way to effectively addressing the gender pay gap in Canada. I would have to write a book to go into all of the detail and complexity but this is a start.

1. Stop holding up or reversing progress on addressing relativity. I am looking at you PTMAs. PTMAs have done an absyssmal job in addressing this issue over the last few decades, in spite of widespread support throughout the profession in favour of action. Relativity and the gender pay gap are slowly becoming one and the same problem- in a US paper released in June, 64 % of relativity (differences in earnings between specialty groups within medicine) could be explained on the basis of gender. https://journals.lww.com/academicmedicine/Abstract/9000/When_a_Specialty_Becomes__Women_s_Work___Trends_in.97144.aspx PTMAs cannot address the gender pay gap unless relativity is simultaneously and effectively addressed since they are becoming largely the same problem. In fact, I would argue it always has been a gender issue, which partly explains the massive failure of having it dealt with adequately, given the lack of women in leadership. Which brings up the next point….

2. Negotiating teams should be all female. The idea a single women on a committee is going to actually DO something to close the gap is magical thinking. Believe me, this issue is not at the top of male physicians’ priority lists and women who are given spots in leadership are often not those openly speaking about gender or other equity issues. And even if a single women does have a stated agenda of tackling both relativity and the gender pay gap, the chances that change will happen with a bunch of other men on the committee, negotiating with a bunch of other men is zero. All male negotiating teams (the same ones that brought us increasingly large issues with relativity and the gender pay gap) have been commonplace in Canada over the years. They have not been able to move the needle on the gender pay gap or relativity and in fact in a lot of cases have managed to make both problems worse. This has happened through inaction-such as failure to move away from an antiquated fee for service payment model, and a failure to move away from the private practice/business model of running an office- both of these systems disadvantage female physicians financially much more than men. Actions such as accepting incorporation in lieu of fee increases some years ago has further cemented and therefore made it more difficult to get away from these payment and business models, while disproportionately benefitting high billers who are mostly men. To the men (and some women) who say it is simply too difficult to get away from FFS and physicians running offices, I say get out of the way. Lean out, move over, resign, and let some of the exceptional female leaders who have been sidelined for far too long tackle this problem. (I don’t actually think we will see all female teams, because patriarchy, but in suggesting an extreme, maybe women physicians can at least see themselves represented in numbers at least in proportion the their membership numbers)

3. Across the board fee increases (which worsen both relativity and the gender pay gap) should be banned as being accepted by all PTMAs in any form until issues of relativity and the gender pay gap are addressed. If you are going to stick with an outdated payment model (fee for service), with the relativity differences we see right now, anything across the board is grossly unfair. Specialties that bill lots of codes (already those with mostly male high billers) will always have much larger increases in their annual incomes than those who do not after an across the board increase. Because math. Priortizing negotiation of complexity codes in primary care for example would be one example of a helpful step. But again, I don’t see fiddling with codes in a Schedule of Benefits as anything but unsuccessful tinkering when it comes to the gender pay gap/relativity, but at least a policy against across the board increases wouldn’t let things worsen substantially. Fee for service will never allow progress to be made meaningfully on the gender pay gap or relativity.

4. PTMAs need billing transparency and as in one very recent and public case in Ontario, to stop using membership money to fund legal fights against billing transparency, when we know salary transparency is an effective tool to close the gender pay gap. The largest group of people who are looking at these numbers is doctors themselves, and I can’t help but think that the release of Ontario physicians billings in the last year by the Toronto Star has helped women physicians understand the magnitude of the pay differences between them and their male colleagues (it was an eye opener for me). I don’t think there is any evidence within the convuluted framework of FFS billings/office expenses that transparency helps to lower the gender pay gap, but it certainly cannot hurt at this point.

I’m just scratching the surface of the gender pay gap in Canadian medicine here. But women physicians should be asking themselves why these things haven’t been done already? By organizations they pay thousands in fees to who are supposed to be representing their financial interests? A lot of attention was paid to a threatened (?performative) defection of specialty groups of majority male high billing specialties in Ontario recently- a process now being repeated in Alberta. These groups who have seen their incomes rise massively while relativity and the gender pay gap go unaddressed- it makes no sense to me that these are the groups who are threatening to leave organizations that have always allowed them to earn more money. It would make more sense to me to see women physicians (and undervalued specialities) threaten and eventually leave PTMAs who refuse to negotiate fair compensation for the largest minority group (women) within their organizations. The time for talking/studying/forming committees about this issue, as with relativity, is well and truly over. “Work is ongoing on this issue” is no longer an acceptable response to the question of what is happening to actually close the dollar figure between what men and women physicians earn in this country. It’s time for action, starting with 1-4 above, setting other concrete goals with fixed timelines, and for people who don’t want to be part of the solution to step back and let in those who want to make the tough decisions and fix the problem.

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