Sex Differences in the Pattern of Patient Referrals to Male and Female Surgeons

"Women's work": Gender and the physician workforce

Historically, the physician professional identity and the organizational structure of Western medicine have been defined by masculine norms such as authority and assertiveness. The past five decades have seen a rapid shift in the demographics of attendees as medical schools, with equal numbers of women and men matriculants for nearly twenty years. Gender as a social, cultural, and structural variable continues to influence the physician workforce. The entry of women into medicine, has had far reaching effects on the expectations of patients, the interactions of physicians with other members of the healthcare team, and the delivery of care. Redefining the culture of medicine to accommodate the diversity of the modern workforce may benefit all physician and improve the delivery of healthcare.

Crowdsourcing the Impact of Illustration in Cleft Surgery Education

OBJECTIVE

This study aimed to (1) assess layperson preferences for how surgical information is presented; (2) evaluate how the format of visual information relates to layperson comfort with undergoing surgery, perceptions of surgeon character traits, and beliefs about artistic skill impacting plastic surgery practice; and (3) identify sociodemographic characteristics associated with these outcomes.

DESIGN

A survey was developed in which one of five standardized sets of information depicting a unilateral cleft lip repair was presented as (1) text alone, (2) quick sketches, (3) simple drawings, (4) detailed illustrations, or (5) photographs.

SETTING

Online crowdsourcing platform.

PARTICIPANTS

Raters aged 18 years and older from the United States.

INTERVENTIONS

None.

MAIN OUTCOME MEASURE(S)

After viewing the surgical information, participants answered three sets of Likert scale questions. Ratings were averaged to produce three composite scores assessing (1) comfort with undergoing surgery (2) perceptions of surgeon character traits, and (3) beliefs about plastic surgery and artistry.

RESULTS

Four hundred seventy-nine participants were included. Surgeon character traits score was highest among participants who viewed detailed illustrations at 4.46 ± 0.59, followed by photographs at 4.43 ± 0.54, text alone at 4.28 ± 0.59, simple drawings at 4.17 ± 0.67, and quick sketches at 4.17 ± 0.71 (p = 0.0014). Participants who viewed detailed illustrations rated surgical comfort score and plastic surgery and artistry score highest, although differences did not achieve statistical significance.

CONCLUSIONS

Viewing detailed cleft lip repair illustrations was significantly associated with positive perceptions of surgeon character traits. Our data help to contextualize methods of communication and education valued by the public when seeking cleft care.

"I don't know if I can keep doing this": a qualitative investigation of surgeon burnout and opportunities for organization-level improvement

Introduction

Burnout is a pressing issue within surgical environments, bearing considerable consequences for both patients and surgeons alike. Given its prevalence and the unique contextual factors within academic surgical departments, it is critical that efforts are dedicated to understanding this issue. Moreover, active involvement of surgeons in these investigations is critical to ensure viability and uptake of potential strategies in their local setting. Thus, the purpose of this study was to explore surgeons' experiences with burnout and identify strategies to mitigate its drivers at the level of the organization.

Methods

A qualitative case study was conducted by recruiting surgeons for participation in a cross-sectional survey and semi-structured interviews. Data collected were analyzed using reflexive thematic analysis, which was informed by the Areas of Worklife Model.

Results

Overall, 28 unique surgeons participated in this study; 11 surgeons participated in interviews and 22 provided responses through the survey. Significant contributors to burnout identified included difficulties providing adequate care to patients due to limited resources and time available in academic medical centers and the moral injury associated with these challenges. The inequitable remuneration associated with education, administration, and leadership roles as a result of the Fee-For-Service model, as well as issues of gender inequity and the individualistic culture prevalent in surgical specialties were also described as contributing factors. Participants suggested increasing engagement between hospital leadership and staff to ensure surgeons are able to access resources to care for their patients, reforming payment plans and workplace polities to address issues of inequity, and improving workplace social dynamics as strategies for addressing burnout.

Discussion

The high prevalence and negative sequalae of burnout in surgery necessitates the formation of targeted interventions to address this issue. A collaborative approach to developing interventions to improve burnout among surgeons may lead to feasible and sustainable solutions.

Gender distribution of Top Doctors in otolaryngology-head and neck surgery

INTRODUCTION

Our study seeks to understand the profiles of otolaryngologists selected by Castle Connolly's Top Doctor list and how this compares to the entire field of otolaryngology.

METHODS

Top Doctor lists published in Castle Connolly affiliated magazines were analyzed for Otolaryngology, Otolaryngology/Facial Plastic Surgery, or Pediatric Otolaryngology physicians. Only lists published in 2021 or representing the 2021 Top Doctor lists were analyzed. Of the total 39 partnered magazines, 27 met our criteria. Information on the physician was analyzed from the Castle Connolly website and included: gender, education, faculty position, years as a Top Doctor, and certifications of each physician.

RESULTS

879 doctors, 742 (84%) men and 137 women (16%), were included in our analysis. 509 physicians completed a fellowship, 85 (62%) women and 424 (57%) men. The fellowship type varied significantly between gender (p = .002). 122 (14%) Top Doctors completed facial and plastic reconstructive surgery and 111 (91%) were men. Of the women Top Doctors completing a fellowship, 29 (34%) completed a fellowship in pediatric otolaryngology. A logistic regression found that men have an increased odds of being on the Top Doctors list for more years than females (OR: 1.36, p < .001).

CONCLUSION

The percentage of women named as Top Doctors was less than the proportion of women in otolaryngology. This may be attributed to gender differences we found in fellowship type and certification. Further research into the role of otolaryngology subspecialties in selection of Top Doctors is needed to better understand gender differences.

Addressing Barriers to Entry and Retention of Women in Interventional Vascular Specialties With Proposed Solutions: A Scientific Statement From the American Heart Association

Representation of women in interventional vascular fields (interventional cardiology, interventional radiology, and vascular surgery) lags behind that in other specialties. With women representing half of all medical school graduates, encouraging parity of women in these fields needs to start in medical school. Barriers to pursuing careers in vascular intervention include insufficient exposure during core clerkships, early mentorship, visibility of women in the field, length of training, lifestyle considerations, work culture and environment, and concerns about radiation exposure. This scientific statement highlights potential solutions for both the real and perceived barriers that women may face in pursuing careers in vascular intervention, including streamlining of training (as both interventional radiology and vascular surgery have done with a resultant increase in percentage of women trainees), standardization of institutional promotion of women in leadership, and professional and industry partnerships for the retention and advancement of women.

Sex Disparities in Ophthalmology From Training Through Practice: A Systematic Review

Importance

Sex-based research in medicine has revealed inequities against females on almost every metric at almost every career stage; ophthalmology is no exception.

Objective

To systematically review the experiences of females in ophthalmology (FiO) from training through practice in high-income countries (HICs).

Evidence Review

A systematic review of English-language studies, published between January 1990 and May 2022, relating to FiO in HICs was performed. PubMed, MEDLINE, and Embase electronic databases were searched, as well as the Journal of Academic Ophthalmology as it was not indexed in the searched databases. Studies were organized by theme at each career stage, starting in medical school when an interest in ophthalmology is expressed, and extending up to retirement.

Findings

A total of 91 studies, 87 cross-sectional and 4 cohort, were included. In medical school, mentorship and recruitment of female students into ophthalmology was influenced by sex bias, with fewer females identifying with ophthalmologist mentors and gender stereotypes perpetuated in reference letters written by both male and female referees. In residency, females had unequal learning opportunities, with lower surgical case volumes than male trainees and fewer females pursued fellowships in lucrative subspecialties. In practice, female ophthalmologists had lower incomes, less academic success, and poorer representation in leadership roles. Female ophthalmologists had a greater scholarly impact factor than their male counterparts, but this was only after approximately 30 years of publication experience. Pervasive throughout all stages of training and practice was the experience of greater sexual harassment among females from both patients and colleagues. Despite these disparities, some studies found that females reported equal overall career satisfaction rating with males in ophthalmology, whereas others suggested higher burnout rates.

Conclusions and Relevance

Ophthalmology is approaching sex parity, however, the increase in the proportion of females in ophthalmology had not translated to an increase in female representation in leadership positions. Sex disparities persisted across many domains including recruitment, training, practice patterns, academic productivity, and income. Interventions may improve sex equity in the field.

Importance of Diversity, Equity, and Inclusion in the Hepatopancreatobiliary Workforce

Diversity is a catalyst for progress that prevents institutional stagnation and, by extension, averts descent to mediocrity. This review focuses on the available data concerning hepatopancreatobiliary (HPB) surgical workforce demographics and identifies evidence-based strategies that may enhance justice, equity, diversity, and inclusion for HPB surgeons and their patients. We report that the current United States HPB surgical workforce does not reflect the population it serves. We review data describing disparity-perpetuating hurdles confronting physicians from minority groups underrepresented in medicine at each stage of training. We further examine evidence showing widespread racial and socioeconomic disparities in HPB surgical care and review the effects of workforce diversity and physician-patient demographic concordance on healthcare outcomes. Evidence-based mitigators of structural racism and segregation are reviewed, including tailored interventions that can address social determinants of health toward the achievement of true excellence in HPB surgical care. Lastly, select evidence-based data driving surgical workforce solutions are reviewed, including intentional compensation plans, mentorship, and sponsorship.

The Cost of Being a Woman in Academic Cardiothoracic Surgery: Joint Collaboration of The Society of Thoracic Surgeons Workforces on Diversity, Equity, and Inclusion and Cardiothoracic Surgery Practice Models

BACKGROUND

Gender disparity in the cardiothoracic surgery workforce is challenging to enumerate and quantify. The purpose of our work is to use the most current data to quantify the percentage of women in academic cardiothoracic surgery and salary disparity between women and men.

METHODS

We performed a cross-sectional analysis of data collected by the Accreditation Council for Graduate Medical Education Data Resource Book 2021 and Association of American Medical Colleges Faculty Data for U.S. Medical School Faculty 2019, 2020, and 2021. We used descriptive analysis of the number of faculty and mean salaries of academic cardiothoracic surgeons according to academic rank and gender. Salary disparity in cardiothoracic surgery was compared with salary disparities seen among surgical specialties and academic clinicians.

RESULTS

Over the past 3 years, women comprised 11.5% of the cardiothoracic workforce. In 2021, cardiothoracic surgeons who were women earned $0.71 to $0.86 for every $1.00 earned by cardiothoracic surgeons who were men. Ascending academic rank correlated with greater gender salary disparity; women professors earned less than men of equal and lower academic rank. From 2019 to 2021, women of the academic ranks of associate professor, professor, and chief of cardiothoracic surgery experienced a decrease in mean salaries, whereas men of equivalent academic ranks experienced an increase in mean salaries.

CONCLUSIONS

Gender disparity in cardiothoracic surgery persists, with low representation of women and salary disparity at every academic rank.

Barriers and Facilitators to Clinical Practice Development in Men and Women Surgeons

Importance

Many early-career surgeons struggle to develop their clinical practices, leading to high rates of burnout and attrition. Furthermore, women in surgery receive fewer, less complex, and less remunerative referrals compared with men. An enhanced understanding of the social and structural barriers to optimal growth and equity in clinical practice development is fundamental to guiding interventions to support academic surgeons.

Objective

To identify the barriers and facilitators to clinical practice development with attention to differences related to surgeon gender.

Design, Setting, and Participants

A multi-institutional qualitative descriptive study was performed using semistructured interviews analyzed with a grounded theory approach. Interviews were conducted at 5 academic medical centers in the US between July 12, 2022, and January 31, 2023. Surgeons with at least 1 year of independent practice experience were selected using purposeful sampling to obtain a representative sample by gender, specialty, academic rank, and years of experience.

Main Outcomes and Measures

Surgeon perspectives on external barriers and facilitators of clinical practice development and strategies to support practice development for new academic surgeons.

Results

A total of 45 surgeons were interviewed (23 women [51%], 18 with ≤5 years of experience [40%], and 20 with ≥10 years of experience [44%]). Surgeons reported barriers and facilitators related to their colleagues, department, institution, and environment. Dominant themes for both genders were related to competition, case distribution among partners, resource allocation, and geographic market saturation. Women surgeons reported additional challenges related to gender-based discrimination (exclusion, questioning of expertise, role misidentification, salary disparities, and unequal resource allocation) and additional demands (related to appearance, self-advocacy, and nonoperative patient care). Gender concordance with patients and referring physicians was a facilitator of practice development for women. Surgeons suggested several strategies for their colleagues, department, and institution to improve practice development by amplifying facilitators and promoting objectivity and transparency in resource allocation and referrals.

Conclusions and Relevance

The findings of this qualitative study suggest that a surgeon's external context has a substantial influence on their practice development. Academic institutions and departments of surgery may consider the influence of their structures and policies on early career surgeons to accelerate practice development and workplace equity.

Gender Differences in Medicare Practice and Payments to Neurosurgeons

Importance

Despite efforts to promote diversity within the neurosurgical workforce, individuals from underrepresented groups face significant challenges.

Objective

To compare practice metrics and earning potential between female and male neurosurgeons and investigate factors associated with gender disparity in Medicare reimbursement.

Design, Setting, and Participants

This retrospective cross-sectional study used publicly accessible Medicare data on reimbursements to female and male neurosurgeons for procedural and evaluation and management services delivered in both inpatient and outpatient settings between January 1, 2013, and December 31, 2020. Data were analyzed from December 9, 2021, to December 5, 2022.

Main Outcomes and Measures

The primary outcome was the mean annual payments received and charges submitted by female and male neurosurgeons for services rendered between 2013 and 2020. Secondary outcomes included the total number and types of services rendered each year and the number of beneficiaries treated. Univariate and multivariable analyses quantified differences in payment, practice volume, and composition.

Results

A total of 6052 neurosurgeons (5540 men [91.54%]; 512 women [8.46%]) served the Medicare fee-for-service patient population. Female neurosurgeons billed for lesser Medicare charges (mean [SE], $395 851.62 [$19 449.39] vs $766 006.80 [$11 751.66]; P < .001) and were reimbursed substantially less (mean [SE], $69 520.89 [$2701.30] vs $124 324.64 [$1467.93]; P < .001). Multivariable regression controlling for practice volume metrics revealed a persistent reimbursement gap (-$24 885.29 [95% CI, -$27 964.72 to -$21 805.85]; P < .001). Females were reimbursed $24.61 less per service than males even after matching services by code (P = .02).

Conclusions and Relevance

This study found significant gender-based variation in practice patterns and reimbursement among neurosurgeons serving the Medicare fee-for-service population. Female surgeons were reimbursed less than male surgeons when both performed the same primary procedure. Lower mean reimbursement per service may represent divergence in billing and coding practices among females and males that could be the focus of future research or educational initiatives.

Evaluation of Medicare Reimbursement and Surgical Patterns for Male and Female Colorectal Surgeons

INTRODUCTION

There are documented differences in salary for male and female surgeons. Understanding the differences in the clinical practice, composition of male and female surgeons may provide a better understanding of reimbursement differences. We aim to evaluate the differences of Medicare reimbursement for different categories of clinical practice for male and female colorectal surgeons.

METHODS

This retrospective cohort study compared Medicare claims made by male and female board-certified colorectal surgeons from the Medicare Provider Utilization and Payment Data between 2013 and 2017. Medicare claims were categorized by surgeon gender. Submitted claims were evaluated based on the following seven procedure categories: open abdominal surgery, laparoscopic abdominal surgery, anorectal surgery, diagnostic endoscopy, therapeutic endoscopy, and inpatient/outpatient services. The main outcomes were number of charges submitted by clinical activity category and procedural code variation billed through Medicare. Secondary outcome was category of procedure activity that each surgeon cohort had participated in.

RESULTS

A total of 62,866 claims were reviewed, of which 10,058 (16.0%) were made by female surgeons and 52,808 (84.0%) were made by male surgeons. On average, male surgeons submitted more claims per year, a greater variety of claims per year, and higher revenue generating claims than female surgeons (P < 0.001).

CONCLUSIONS

Male and female colorectal surgeons may participate in different categories of clinical activities that result in male surgeons performing more and higher relative value units-generating activity than female surgeons.

Return to sender: Unraveling the role of structural and social network ties in patient sharing networks

Healthcare is increasingly delivered through networks of organizations. Well-structured patient sharing networks are known to have positive associations with the quality of delivered services. However, the drivers of patient sharing relations are rarely studied explicitly. In line with recent developments in network and integration theorizing, we hypothesize that structural and social network ties between organizations are uniquely associated with a higher number of shared patients. We test these hypotheses using a Bayesian zero-dispersed Poisson regression model within the Additive and Multiplicative Effects Framework based on administrative claims data from 732,122 dermatological patients from the Netherlands in 2017. Our results indicate that 2.6% of all dermatological patients are shared and that the amount of shared patients is significantly associated with structural (i.e. emergency contracts) and social (i.e. shared physicians) ties between organizations, confirming our hypotheses. We also find some evidence that patients are shared with more capable organizations. Our findings highlight the role of relational ties in the way health services are delivered. At the same time, they also raise some potential anti-trust concerns.

Association of patient-practitioner sex concordance with specialist referral in primary hyperparathyroidism

BACKGROUND

Prior research has demonstrated barriers to the workup and management of primary hyperparathyroidism. As recent data have suggested that patient and practitioner sex concordance is associated with lower surgical complications, we sought to evaluate the effect of sex concordance on referral for primary hyperparathyroidism.

METHODS

We queried an institutional database for patients with first-incident hypercalcemia and subsequent biochemical evidence of primary hyperparathyroidism between 2010 and 2018. Primary care practitioner and endocrinologist sex, laboratory values, and complications of primary hyperparathyroidism were collected. Sex concordance (male patient/male practitioner or female patient/female practitioner) was evaluated as a binary predictor of specialist evaluation using logistic regression and Cox proportional hazards modeling.

RESULTS

Among 1,100 patients, mean age was 62.5 (standard deviation 13.6), and 74% were female sex. Primary care practitioner sex was 52% female, and 63% of patients had sex concordance with their primary care practitioner. Endocrinologist sex was 59% female, and 45% of patients had sex concordance with their endocrinologist. Patients with sex concordance with their primary care practitioner (70 vs 80%, P = .001) and endocrinologist (71 vs 82%, P < .001) were less likely to be female sex compared to those with discordance. After adjusting for demographics and clinical covariates, those patients with primary care practitioner sex concordance had 32% higher odds of endocrinologist evaluation (odds ratio 1.32, 95% confidence interval 1.003-1.734, P = .047). Similarly, those patients with endocrinologist sex concordance had a 48% higher rate of surgeon evaluation (hazard ratio 1.48, confidence interval 1.1-2.0, P = .009). Stratified analysis revealed that sex discordance reduced the rate of surgeon referral for female patients (hazard ratio 0.63, confidence interval 0.44-0.89, P = .008) but not male patients (hazard ratio 1.06, CI 0.58-1.93, P = .861).

CONCLUSION

Sex discordance between patients and their health care professionals may contribute to under-referral in primary hyperparathyroidism. Further evaluation of the effect of patient and practitioner identities on communication and decision-making in surgery are needed.

Feasibility and Safety of a "Shared Care" Model in Complex Hepatopancreatobiliary Surgery: A 5-year Observational Study of Outcomes in Pancreaticoduodenectomy

OBJECTIVE

To determine the safety of a fully functioning shared care model (SCM) in hepatopancreatobiliary surgery through evaluating outcomes in pancreaticoduodenectomy.

BACKGROUND

SCMs, where a team of surgeons share in care delivery and resource utilization, represent a surgeon-level opportunity to improve system efficiency and peer support, but concerns around clinical safety remain, especially in complex elective surgery.

METHODS

Patients who underwent pancreaticoduodenectomy between 2016 and 2020 were included. Adoption of shared care was demonstrated by analyzing shared care measures, including the number of surgeons encountered by patients during their care cycle, the proportion of patients with different consenting versus primary operating surgeon (POS), and the proportion of patients who met their POS on the day of surgery. Outcomes, including 30-day mortality, readmission, unplanned reoperation, sepsis, and length of stay, were collected from the institution's National Surgical Quality Improvement Program (NSQIP) database and compared with peer hospitals contributing to the pancreatectomy-specific NSQIP collaborative.

RESULTS

Of the 174 patients included, a median of 3 surgeons was involved throughout the patients' care cycle, 69.0% of patients had different consenting versus POS and 57.5% met their POS on the day of surgery. Major outcomes, including mortality (1.1%), sepsis (5.2%), and reoperation (7.5%), were comparable between the study group and NSQIP peer hospitals. Length of stay (10 day) was higher in place of lower readmission (13.2%) in the study group compared with peer hospitals.

CONCLUSIONS

SCMs are feasible in complex elective surgery without compromising patient outcomes, and wider adoption may be encouraged.

Association between patient-surgeon gender concordance and mortality after surgery in the United States: retrospective observational study

OBJECTIVE

To determine whether patient-surgeon gender concordance is associated with mortality of patients after surgery in the United States.

DESIGN

Retrospective observational study.

SETTING

Acute care hospitals in the US.

PARTICIPANTS

100% of Medicare fee-for-service beneficiaries aged 65-99 years who had one of 14 major elective or non-elective (emergent or urgent) surgeries in 2016-19.

MAIN OUTCOME MEASURES

Mortality after surgery, defined as death within 30 days of the operation. Adjustments were made for patient and surgeon characteristics and hospital fixed effects (effectively comparing patients within the same hospital).

RESULTS

Among 2 902 756 patients who had surgery, 1 287 845 (44.4%) had operations done by surgeons of the same gender (1 201 712 (41.4%) male patient and male surgeon, 86 133 (3.0%) female patient and female surgeon) and 1 614 911 (55.6%) were by surgeons of different gender (52 944 (1.8%) male patient and female surgeon, 1 561 967 (53.8%) female patient and male surgeon). Adjusted 30 day mortality after surgery was 2.0% for male patient-male surgeon dyads, 1.7% for male patient-female surgeon dyads, 1.5% for female patient-male surgeon dyads, and 1.3% for female patient-female surgeon dyads. Patient-surgeon gender concordance was associated with a slightly lower mortality for female patients (adjusted risk difference -0.2 percentage point (95% confidence interval -0.3 to -0.1); P<0.001), but a higher mortality for male patients (0.3 (0.2 to 0.5); P<0.001) for elective procedures, although the difference was small and not clinically meaningful. No evidence suggests that operative mortality differed by patient-surgeon gender concordance for non-elective procedures.

CONCLUSIONS

Post-operative mortality rates were similar (ie, the difference was small and not clinically meaningful) among the four types of patient-surgeon gender dyads.

Mapping a shared care model in complex gastrointestinal surgery: A qualitative study of queues and stakeholders within a Canadian general surgery practice

Shared Care Models (SCMs), in which a team of clinicians share in patient care and resource utilization, represent an opportunity for surgeon-level system change. We aimed to identify the queues and stakeholders within a complex gastrointestinal surgical care pathway to demonstrate the implications of a SCM on system efficiency. A multidisciplinary group of surgeons and care navigators working in SCMs were asked to develop a patient encounter map through consensus to illustrate relevant queues and stakeholders within a SCM. Fifteen surgeon-related queues were identified, each representing a point of potential delay to care in the patient's journey that could be addressed by shared care. A final patient encounter map was created, and advantages and challenges of SCMs were also described from multidisciplinary group discussions. The numerous queues identified in this map ultimately reflected opportunities for more efficient care navigation under a SCM through increased surgeon availability and shared resource utilization.

The impact of targeted fee increases on the pay disparity between female and male general surgeons in British Columbia

BACKGROUND

High-level payment data provided by Doctors of BC showed a 19.7% pay disparity in annual payments between female and male general surgeons in fiscal year 2019/20, and this was previously as high as 30% in 2012/13. This study aimed to examine the impact of targeted fee increases on pay disparity by sex over time.

METHODS

The top 35 fees billed by female general surgeons, representing 76.3% of total payments, were retrospectively analyzed. The pay disparity by sex was calculated for each individual fee from 2000/01 to 2019/20.

RESULTS

There were notable billing differences between female and male general surgeons. Female surgeons billed breast oncology procedures, malignancy consultations and visits, and peritoneal malignancy surgical procedures in greater proportions than did their male counterparts. Male surgeons billed hemorrhoid banding and rigid proctosigmoidoscopy in greater proportions than their female counterparts. With targeted fee increases, pay disparity by sex worsened for 17 of the top 35 fees but improved for the other 18 from 2010/11 to 2019/20, to varying degrees, resulting in an overall reduction in pay disparity by sex from 23% to 15%. If across-the-board fee increases had been implemented instead of targeted fee increases, the disparity in 2019/20 would have been 19% instead of 15%.

CONCLUSION

Targeted fee increases reduced pay disparity between male and female general surgeons compared with theoretical across-the-board fee increases in British Columbia from 2010/11 to 2019/20, but not uniformly; some fee increases resulted in increased disparity. Other physician groups should conduct a similar analysis and allocate future fee changes with the aim of improving rather than worsening disparity.

Gender Inequity in the Clinical Setting

Women in surgery continue to face inequitable treatment from surgical leadership, their peers, hospital staff, and even from their patients. Despite this, women surgeons continue to produce equal, or improved, clinical outcomes for their patients, with their work being given less remuneration than that of their male peers. The cultural stereotypes and biases that drive these inequities are implicit and subtle; however, they have dramatic effects on the lives and careers of women surgeons.

Referring and Specialist Physician Gender and Specialist Billing

Importance

While a gender pay gap in medicine has been well documented, relatively little research has addressed mechanisms that mediate gender differences in referral income for specialists.

Objective

To examine gender-based disparities in medical and surgical specialist referrals in Ontario, Canada.

Design, Setting, and Participants

This cross-sectional study included referrals for specialist care ascertained from Ontario Health Insurance Plan physician billings for fiscal year 2018 to 2019. Participants were specialist physicians who received new patient consultations from April 1, 2018, to March 31, 2019, and the associated referring physicians. Data were analyzed from April 2018 to March 2020, including a 12-month follow-up period.

Exposures

Specialist and referring physician gender (female or male).

Main Outcomes and Measures

Revenue per referral was defined based on an episode-of-care approach as total billings for a 12-month period from the initial consultation. Mean total billings for female and male specialists were compared and the differential divided into the portion owing to referral volume vs referral revenue. Difference-in-differences multivariable regression analysis was used to estimate gender-based differences in revenue per referral. For each referring physician, gender-based differences in referral patterns were examined using case-control analysis, in which specialists who received a referral were compared with matched control specialists who did not receive a referral. This analysis considered the gender of the specialist and concordance between the gender of the referring physician and specialist, among other characteristics.

Results

Of 7 621 365 new referrals, 32 824 referring physicians, of whom 13 512 (41.2%) were female (mean [SD] age, 46.3 [11.6] years) and 19 312 (58.8%) were male (mean [SD] age, 52.9 [13.5] years), made referrals to 13 582 specialists, of whom 4890 (36.0%) were female (mean [SD] age, 45.6 [11.0] years) and 8692 (64.0%) were male (mean [SD] age, 51.8 [13.0] years). Male specialists received more mean (SD) referrals than did female specialists (633 [666] vs 433 [515]), and the mean (SD) revenue per referral was higher for males ($350 [$474]) compared with females ($316 [$393]). Adjusted analysis demonstrated a -4.7% (95% CI, -4.9% to -4.5%) difference in the revenue per referral between male and female specialists. Multivariable regression analysis found that physicians referred more often to specialists of the same gender (odds ratio, 1.04; 95% CI, 1.03-1.04) but had higher odds of referring to male specialists (odds ratio, 1.10; 95% CI, 1.09-1.11).

Conclusions and Relevance

In this cross-sectional study of the gender pay gap in specialist referral income, the number and revenue from referrals received differed by gender, as did the odds of receiving a referral from a physician of the same gender. Future research should examine the effectiveness of different policies to address this gap, such as a centralized, gender-blinded referral system.

Workforce Attrition Among Male and Female Physicians Working in US Academic Hospitals, 2014-2019

Importance

Retaining female physicians in the academic health care workforce is necessary to serve the needs of sociodemographically diverse patient populations.

Objective

To investigate differences in rates of leaving academia between male and female physicians.

Design, Setting, and Participants

This cohort study used Care Compare data from the Centers for Medicare & Medicaid Services for all physicians who billed Medicare from teaching hospitals from March 2014 to December 2019, excluding physicians who retired during the study period. Data were analyzed from November 11, 2021, to May 24, 2022.

Exposure

Physician gender.

Main Outcome and Measures

The primary outcome was leaving academia, which was defined as not billing Medicare from a teaching hospital for more than 1 year. Multivariable logistic regression was conducted adjusting for physician characteristics and region of the country.

Results

There were 294 963 physicians analyzed (69.5% male). The overall attrition rate from academia was 34.2% after 5 years (38.3% for female physicians and 32.4% for male physicians). Female physicians had higher attrition rates than their male counterparts across every career stage (time since medical school graduation: <15 years, 40.5% vs 34.8%; 15-29 years, 36.4% vs 30.3%; ≥30 years, 38.5% vs 33.3%). On adjusted analysis, female physicians were more likely to leave academia than were their male counterparts (odds ratio, 1.25; 95% CI, 1.23-1.28).

Conclusions and Relevance

In this cohort study, female physicians were more likely to leave academia than were male physicians at all career stages. The findings suggest that diversity, equity, and inclusion efforts should address attrition issues in addition to recruiting more female physicians into academic medicine.

Assessment of Demographic Changes of Workforce Diversity in Otolaryngology, 2013 to 2022

Importance

Given the growth of minoritized groups in the US and the widening racial and ethnic health disparities, improving diversity remains a proposed solution in the field of otolaryngology. Evaluating current trends in workforce diversity may highlight potential areas for improvement.

Objective

To understand the changes in gender, racial, and ethnic diversity in the otolaryngology workforce in comparison with changes in the general surgery and neurosurgery workforces from 2013 to 2022.

Design, Setting, and Participants

This cross-sectional study used publicly available data from the Accreditation Council for Graduate Medical Education and the Association of American Medical Colleges for 2013 to 2022, and included medical students and trainees in all US medical residency programs and allopathic medical schools.

Main Outcomes and Measures

Average percentages of women, Black, and Latino trainees during 2 intervals of 5 years (2013-2017 and 2018-2022). Pearson χ2 tests compared demographic information. Normalized ratios were calculated for each demographic group in medical school and residency. Piecewise linear regression assessed linear fit for representation across time periods and compared rates of change.

Results

The study population comprised 59 865 medical residents (43 931 [73.4%] women; 6203 [10.4%] Black and 9731 [16.2%] Latino individuals; age was not reported). The comparison between the 2 study intervals showed that the proportions of women, Black, and Latino trainees increased in otolaryngology (2.9%, 0.7%, and 1.6%, respectively), and decreased for Black trainees in both general surgery and neurosurgery (-0.4% and -1.0%, respectively). In comparison with their proportions in medical school, Latino trainees were well represented in general surgery, neurosurgery, and otolaryngology (normalized ratios [NRs]: 1.25, 1.06, and 0.96, respectively); however, women and Black trainees remained underrepresented in general surgery, neurosurgery, and otolaryngology (women NRs, 0.76, 0.33, and 0.68; Black NRs, 0.63, 0.61, and 0.29, respectively). The percentage of women, Black, and Latino trainees in otolaryngology all increased from 2020 to 2022 (2.5%, 1.1%, and 1.1%, respectively). Piecewise regression showed positive trends across all 3 specialties.

Conclusions and Relevance

The findings of this cross-sectional study indicate a positive direction but only a modest increase of diversity in otolaryngology, particularly in the context of national demographic data. Novel strategies should be pursued to supplement existing efforts to increase diversity in otolaryngology.

New Patient Referral Patterns May Reflect Gender Biases in Orthopedics

Background Orthopedic surgery traditionally has been a male-dominant specialty with the lowest percentage of female residents and female faculty of all medical specialties. Prior studies demonstrate gender biases from both referring providers and patients. This study investigates surgeon, referring provider, and patient demographic differences in new patient orthopedic referrals. Methodology A retrospective chart review was performed to analyze the demographics of new patients referred to male and female orthopedic surgeons within adult reconstruction and shoulder/elbow specialties at a single academic institution. Patients and referring provider demographics were compared for male and female orthopedic surgeons. Statistical analysis utilized Student's t-test and chi-square analyses for quantitative and qualitative data, respectively. Results In total, 2,642 new patients were analyzed, with 2,084 patients being referred from a provider, and 306 patients requesting specific providers. When compared to male surgeons, female surgeons had fewer referrals from male providers (45.3% vs. 50.3%, p = 0.03) and no difference from female providers (30.6% vs, 29.9%, p = 0.72). The female adult reconstruction surgeon had fewer internal referrals compared to a male surgeon of similar experience and time at the institution (8.4% vs. 12.8%, p = 0.03). Female patients requested male surgeons more frequently than female surgeons (76.7% vs. 23.3%, p = 0.02). Conclusions New patient demographics differed between male and female orthopedic surgeons at a single academic institution with more male referring providers referring to male surgeons. Female patients requesting male orthopedic providers may reflect patient and specialty-driven biases. There remains a need for additional female representation in orthopedic surgery, and new patient referral patterns may be a marker to assess and monitor gender biases.

Structural Sexism and Cancer Care: The Effects on the Patient and Oncologist

Despite progress toward equity within our broad social context, the domains of gender as a social, cultural, and structural variable continue to exert influence on the delivery of oncology care. Although there have been vast advances in our understanding of the biological underpinnings of cancer and significant improvements in clinical care, disparities in cancer care for all women-including cisgender, transgender, and gender diverse women-persist. Similarly, despite inclusion within the oncology physician workforce, women and gender minorities, particularly those with additional identities under-represented in medicine, still face structural barriers to clinical and academic productivity and career success. In this article, we define and discuss how structural sexism influences both the equitable care of patients with cancer and the oncology workforce and explore the overlapping challenges in both realms. Solutions toward creating environments where patients with cancer of any gender receive optimal care and all physicians can thrive are put forward.

Pharmacist gender and physician acceptance of antibiotic stewardship recommendations: An analysis of the reducing overuse of antibiotics at discharge home intervention

OBJECTIVE

To assess association of pharmacist gender with acceptance of antibiotic stewardship recommendations.

DESIGN

A retrospective evaluation of the Reducing Overuse of Antibiotics at Discharge (ROAD) Home intervention.

SETTING

The study was conducted from May to October 2019 in a single academic medical center.

PARTICIPANTS

The study included patients receiving antibiotics on a hospitalist service who were nearing discharge.

METHODS

During the intervention, clinical pharmacists (none who had specialist postgraduate infectious disease residency training) reviewed patients on antibiotics and led an antibiotic timeout (ie, structured conversation) prior to discharge to improve discharge antibiotic prescribing. We assessed the association of pharmacist gender with acceptance of timeout recommendations by hospitalists using logistic regression controlling for patient characteristics.

RESULTS

Over 6 months, pharmacists conducted 295 timeouts: 158 timeouts (53.6%) were conducted by 12 women, 137 (46.4%) were conducted by 8 men. Pharmacists recommended an antibiotic change in 82 timeouts (27.8%), of which 51 (62.2%) were accepted. Compared to male pharmacists, female pharmacists were less likely to recommend a discharge antibiotic change: 30 (19.0%) of 158 versus 52 (38.0%) of 137 (P < .001). Female pharmacists were also less likely to have a recommendation accepted: 10 (33.3%) of 30 versus 41 (8.8%) of 52 (P < .001). Thus, timeouts conducted by female versus male pharmacists were less likely to result in an antibiotic change: 10 (6.3%) of 158 versus 41 (29.9%) of 137 (P < .001). After adjustments, pharmacist gender remained significantly associated with whether recommended changes were accepted (adjusted odds ratio [aOR], 0.10; 95%confidence interval [CI], 0.03-0.36 for female versus male pharmacists).

CONCLUSIONS

Antibiotic stewardship recommendations made by female clinical pharmacists were less likely to be accepted by hospitalists. Gender bias may play a role in the acceptance of clinical pharmacist recommendations, which could affect patient care and outcomes.

Gender Homophily in Interphysician Referrals to Surgeons

INTRODUCTION

The literature on gender homophily has mostly been focused on patient-physician relationship but not on interprofessional referrals. The goal of this study is to quantify interphysician gender homophily of referring physicians in surgical referrals.

METHODS

An observational study of the referral data at a large academic center was performed. Patients referred through Epic to the department of general surgery from January 2016 to October 2019 were included. The primary end point was gender homophily and the primary independent variable was referring physician gender. Gender homophily was defined as greater than expected rates of gender concordance. Gender concordance was defined when referring physicians have the same gender as receiving surgeons. The expected concordance rate was defined as the availability of gender-concordant surgeons in the population. Absolute homophily is the difference between observed and expected concordance rates, whereas relative homophily is the ratio between observed and expected concordance rates.

RESULTS

A total of 25,271 patient referrals from 2625 referring physicians to 91 surgeons were analyzed. The overall observed concordance rate for the entire study population was 55.3% and was 31.7% among female physicians and 82.4% among male physicians. Compared to the expected concordance rate, the absolute gender homophily among all female physicians was +7.2% or a relative homophily of 1.29%. In contrast, the absolute gender homophily among all male physicians was +6.9% or a relative homophily of 1.09%.

CONCLUSIONS

Gender homophily exists in interprofessional referrals. Although referral decisions are presumably based solely on clinical factors, referrals can be affected by subjective biases.

Association of surgeons' gender with elective surgical lists in the State of Florida is explained by differences in mean operative caseloads

BACKGROUND

A recent publication reported that at three hospitals within one academic health system, female surgeons received less surgical block time than male surgeons, suggesting potential gender-based bias in operating room scheduling. We examined this observation's generalizability.

METHODS

Our cross-sectional retrospective cohort study of State of Florida administrative data included all 4,176,551 ambulatory procedural encounters and inpatient elective surgical cases performed January 2017 through December 2019 by 8875 surgeons (1830 female) at all 609 non-federal hospitals and ambulatory surgery centers. There were 1,509,190 lists of cases (i.e., combinations of the same surgeon, facility, and date). Logistic regression adjusted for covariables of decile of surgeon's quarterly cases, surgeon's specialty, quarter, and facility.

RESULTS

Selecting randomly a male and a female surgeons' quarter, for 66% of selections, the male surgeon performed more cases (P < .0001). Without adjustment for quarterly caseloads, lists comprised one case for 44.2% of male and 54.6% of female surgeons (difference 10.4%, P < .0001). A similar result held for lists with one or two cases (difference 9.1%, P < .0001). However, incorporating quarterly operative caseloads, the direction of the observed difference between male and female surgeons was reversed both for case lists with one (-2.1%, P = .03) or one or two cases (-1.8%, P = .05).

CONCLUSIONS

Our results confirm the aforementioned single university health system results but show that the differences between male and female surgeons in their lists were not due to systematic bias in operating room scheduling (e.g., completing three brief elective cases in a week on three different workdays) but in their total case numbers. The finding that surgeons performing lists comprising a single case were more often female than male provides a previously unrecognized reason why operating room managers should help facilitate the workload of surgeons performing only one case on operative (anesthesia) workdays.

Gender Bias in YouTube Videos Describing Common Urology Conditions

OBJECTIVE

To study implicit and explicit gender biases in YouTube videos describing common urologic conditions based on language patterns, speaker gender, and speaker profession.

METHODS

Using a Boolean search, the top 30 videos for benign prostatic hyperplasia (BPH), kidney stones, urinary tract infections (UTIs), overactive bladder (OAB), erectile dysfunction (ED), and pelvic organ prolapse (POP) were retrieved. Using the Linguistic Inquiry and Word Count program (LIWC) software, video transcripts were analyzed for 16 word categories and compared by speaker gender and urology topic to assess for bias.

RESULTS

OAB and POP had the least view counts and subscribers; kidney stone and ED videos had the most. Student education channels were more likely to feature male than female speakers (19 male vs. 6 female, P=0.01). A significant difference was noted between speaker gender in BPH (25 male vs. 4 female, P<0.001), OAB (4 male vs. 22 female, P<0.001), and POP (6 male vs. 23 female, P<0.001) videos. When examining linguistic patterns with the LIWC program, female speakers were more likely to mention personal concerns and use tentative words when speaking alone compared to males.

CONCLUSIONS

Gender bias exists in YouTube videos concerning common urologic conditions. We must be mindful of how information is distributed in order to minimize the perpetuation of gender stereotypes that are common in medicine. Awareness of these patterns and biases should encourage Urologists to proactively consider how they present themselves and how they reference the conditions they present in social media outlets.

The surgical gender gap: the impact of surgeon gender in medicine and gynecologic surgery

PURPOSE OF REVIEW

The purpose of this review is to summarize the current literature evaluating the effect of surgeon gender on patient outcomes and satisfaction, and the impact of gender bias on female surgeons.

RECENT FINDINGS

The proportion of female physicians has increased in recent years, especially in Obstetrics and Gynecology. Recent literature assessing this impact supports equivalent or superior medical and surgical outcomes for women surgeons and physicians. It also reveals superior counseling and communication styles as perceived by patients. However, women in medicine receive lower patient ratings in competence, medical knowledge, and technical skills despite the existing evidence. Additionally, female physicians experience pay inequality, limited advancement opportunities, higher prevalence of microaggressions, and higher rates of burnout.

SUMMARY

Recognition of gender bias is essential to correcting this issue and improving the negative impact it has on female physicians, our patients, and the field of women's health.

Gender discrimination in surgical oncology: An in-house appraisal

Introduction

Gender discrimination (GD) though rarely blatant, may present indirectly within a surgical department in the form of subtle inequities, differing standards, and bias. GD encompasses a wide spectrum including academic development, surgical opportunities and sexual harassment.

Methods

We conducted an online survey to analyse the perceived incidence of GD in the surgical oncology department at a tertiary care cancer centre in India. The questionnaire consisted of 15 questions and was mailed to the entire department including trainees and faculty. Anonymity was maintained while collecting the data only of the participants' gender and whether they were faculty or trainee. Collated responses were analysed using proportions.

Results

The questionnaire was sent out to 200 recipients of whom 56% (112/200) responded via an online survey. Respondents included 84% of faculty (42/50) and 46.6% of trainees (70/150). GD was perceived by 28% of female trainees (7/25) as compared to 6.6% of male trainees (3/45), whereas amongst faculty, GD was perceived by 26.6% of female faculty (4/15) compared to 14.8% of male faculty (3/27). Approximately 13% of our trainees and 12% of our faculty mentioned that GD affected their professional performance or mental well-being. GD was experienced in terms of work experience and opportunities by a majority of trainees (13%) and faculty (9.5%). There was a significant lack of awareness about recourse to an institutional grievance committee by trainees (47%) compared to faculty (14%). About 7% of trainees and 12% of faculty acknowledged that they may have been responsible for intentional/unintentional GD.

Conclusion

Gender discrimination can present in subtle or overt fashion in surgical departments and requires active sustained efforts to allow both genders to feel equally empowered. Establishing a system to objectively evaluate gender equity while avoiding stereotyping for certain roles can help minimize GD.

Contemporary Practice of General Surgery in the US: Analysis of American Board of Surgery Diplomate Case Logs

BACKGROUND

The demographics and operative experience of general surgeons certified by the American Board of Surgery were last examined a decade ago. This study examines the contemporary workforce and scope of practice of general surgeons.

STUDY DESIGN

Applications of diplomates seeking American Board of Surgery recertification from 2013 to 2017 were reviewed. Demographic data and case logs from the year before submission were analyzed. Total operative volume was examined, as were total volumes for 13 operative domains and 11 abdominal and alimentary tract subdomains.

RESULTS

There were 4,735 general surgeons certified by the American Board of Surgery with a mean ± SD age of 53 ± 8 years and included 19% women and 14% international graduates. Regions of practice were 22% Northeast, 31% Southeast, 20% Midwest, 20% West, and 7% Southwest. Practice settings were 86% urban, 9% large rural, 4% small rural, and 1% isolated. Forty-one percent were 10 years, 35% were 20 years, and 24% were 30 years since initial certification. On average, general surgeons performed 417 ± 338 procedures per year, with abdominal, alimentary tract, and endoscopy being the most common. On multivariable analysis, male sex and being midcareer or late career were positively associated with being a high-volume (top quartile) surgeon, whereas age and practicing in either the Northeast or West demonstrated a negative association.

CONCLUSIONS

The demographics of general surgeons have remained stable over time, except for an increased proportion of female surgeons. The overall operative experience is similar to years past but is widely variable between surgeons. Periodic analysis of these data is important for education and certification purposes.

A Woman's Place Is in Theatre, but Are Theatres Designed with Women in Mind? A Systematic Review of Ergonomics for Women in Surgery

Background: Literature regarding ergonomic protocols for surgery is lacking, and there is a paucity of information on how this impacts on gender differences with regards to the barriers faced by women in surgery. Methods: This article reviews current literature addressing women in surgery and ergonomics through a systematic search including the Web of Science, Scopus, and PubMed databases. Results: Searches retrieved 425 items, and after a thorough evaluation for inclusion, 15 studies were examined—predominantly surveys (n = 9) and originating from the USA (n = 9). Identified ergonomic challenges included the general shorter height and smaller glove size of women. Furthermore, women experienced more musculoskeletal pain than men, potentially because the size and design of theatre tools are designed for male and tall individuals, highlighting an unconscious gender bias still pervading the surgical field. Conclusions: As more women enter medicine and pursue surgical careers, it is essential to foster a culture of diversity and inclusion in theatre to develop more ergonomic environments.

Gender Representation Among Presenters in Ophthalmology Subspecialties in 2019: A Retrospective Review

PURPOSE

To describe gender representation at eight national ophthalmology conferences, stratified by role, session category, and sub-specialty.

DESIGN

Retrospective cross-sectional study.

STUDY POPULATION

3,817 presenters at the 2019 American Academy of Ophthalmology subspecialty days, American Society of Cataract and Refractive Surgery, American Glaucoma Society, American Society of Retina Specialists, American Society of Ophthalmic Plastic and Reconstructive Surgery, American Association for Pediatric Ophthalmology and Strabismus, North American Neuro-Ophthalmology Society, and American Uveitis Society meetings.

MAIN OUTCOME MEASURES

Gender of presenters in seven sub-specialties stratified by category and role.

RESULTS

The proportion of female presenters was less than the ABO-estimated proportion of women in their respective fields in glaucoma (28.0% vs. 39.8%), neuro-ophthalmology (35.3% vs. 45.3%), and pediatrics (42.1% vs. 53.3%) and greater than expected in retina (24.6% vs. 19.8%). Overall, the proportion of female presenters exceeded the ABO-estimated proportion of females in ophthalmology (24.5%) for clinical (mean: 38.5%, 95% CI: [35.8%, 41.4%]) and scientific (39.4% [30.3%, 49.2%]) sessions. For clinical sub-specialty sessions, the proportion of female leaders exceeded the overall proportion of female leaders in the respective sub-specialty in cornea (35.1%, [30.4%, 40.1%] vs. 24.6% all sessions). Females represented fewer than the expected number of surgical session leaders in cornea (22.0% [19.9%, 24.3%]), glaucoma (18.0% [13.2%, 24.1%]), pediatrics (22.0% [14.4%, 32.1%]), and retina (18.6% [14.2%, 24.1%]).

CONCLUSIONS

Gender representation varied, with fewer than expected female presenters in glaucoma, neuro-ophthalmology, and pediatrics. Females led relatively more clinical sessions, but were underrepresented in surgical sessions, in most sub-specialties.

Benchmarking Surgeons’ Gender and Year of Medical School Graduation Associated With Monthly Operative Workdays for Multispecialty Groups

Background

Female surgeons reportedly receive less surgical block time and fewer procedural referrals than male surgeons. In this study, we compared operative days between female and male surgeons throughout Florida. Our objective was to facilitate benchmarking by multispecialty groups, both the endpoint to use for statistically reliable results and expected differences.

Methodology

The historical cohort study included all 4,060,070 ambulatory procedural encounters and inpatient elective surgical states performed between January 2017 and December 2019 by 8,472 surgeons at 609 facilities. Surgeons’ gender, year of medical school graduation, and surgical specialty were obtained from their National Provider Identifiers.

Results

Female surgeons operated an average of 1.0 fewer days per month than matched male surgeons (99% confidence interval 0.8 to 1.2 fewer days, P < 0.0001). The mean differences were 0.8 to 1.4 fewer days per month among each of the five quintiles of years of graduation from medical school (all P ≤ 0.0050). Results were comparable when repeated using the number of monthly cases the surgeons performed.

Conclusions

An average difference of ≤1.4 days per month is a conservative estimate for the current status quo of the workload difference in Florida. Suppose that a group’s female surgeons average more than two fewer operative days per month than the group’s male surgeons of the same specialty. Such a large average difference would call for investigation of what might reflect systematic bias. While such a difference may reflect good flexibility of the organization, it may show a lack of responsiveness (e.g., fewer referrals of procedural patients to female surgeons or bias when apportioning allocated operating room time).

Improving Equity, Diversity, and Inclusion in Plastic, Reconstructive, and Aesthetic Surgery in Canada: A Call to Action

The global COVID-19 pandemic has brought to light the significant inequities in the delivery of healthcare, vaccine inequity, and differential access to life-saving treatments, which have disproportionately impacted marginalized and racialized populations. In this article, we acknowledge and recognize the centuries-old legacies perpetuating inequity, injustice, and oppression, we discuss the principles of Equity, Diversity, and Inclusion (EDI) and we call our Canadian plastic surgery colleagues and trainees to action. We propose a plan for (1) Education, (2) Mitigating Disparities in the Clinical Setting, and (3) Policy, Societies, and Leadership Education.