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Bias and Female Surgeons

A female surgeon in the operating room

A new JAMA study has revealed significant gender bias against female surgeons in Ontario. But a post-pandemic world may hold the key to a more equitable system and, ultimately, better patient care.

Dr. Fahima Dossa strikes a surprising note of optimism, even when discussing a major new study she co-authored on gender bias. The research paper, called “Sex Differences in the Pattern of Patient Referrals to Male and Female Surgeons” and published in JAMA Surgery in November 2021, paints a stark picture of how referrals to surgeons work in Ontario. The study examined 20 years of data (1997 to 2016), comprised of nearly 40 million referrals to more than 5,600 surgeons, and the evidence was clear: despite women playing a proportionately larger role in the medical profession over this period, biases against them have persisted.

Indeed, as the study points out, male surgeons accounted for 77.5 percent of all surgeons, but received 87.1 percent of referrals from male physicians and 79.3 percent of referrals from female physicians. After adjusting for differences in experience levels, female physicians had a 1.6 percent greater chance of making a same-sex referral, whereas male physicians had a 32 percent greater chance of making a same-sex referral. These differences did not attenuate over time, even as more women joined the profession during the 20-year period under review. (The study authors were unable to ascertain physician gender and relied on biological sex for their analysis; however, given the number of referrals analyzed in this study, they expect that it had little effect on the results.)

Yet Dr. Dossa remains sanguine about the road ahead. The COVID-19 pandemic may present a unique opportunity to address some of the inequities revealed in the study’s findings. This health crisis forced us to look at ways the system overall could run more efficiently, including how referrals to surgeons are divvied up in this province.

We caught up with Dr. Dossa to ask her a few questions about this JAMA publication.

What was the impetus for this study? How did it begin for you and your fellow authors?
In 2019, we published an article in JAMA Surgery examining the gender pay gap in surgery in Ontario. Although a fee-for-service remuneration system, like the one used in Ontario, is thought to theoretically be free of bias that may creep into a salary-based payment model, we showed that a 24 percent gender pay gap still existed in Ontario. As a driver of this, we found that women appeared to have fewer opportunities to perform the more highly remunerative surgical procedures. This got us thinking about how referrals, and any inherent biases in the referral process, could be influencing the gender pay gap in the province.

Your study looks at 20 years of data comprised of nearly 40 million referrals. Were there any surprises in the results?
Absolutely. The expectation was that we would see signals of improvement over time, especially as there has been increasing focus on issues of equity and diversity in recent years. However, this was not the case. In a sub-analysis of the most recent five years of data, there were no signals of improvement. Another expectation was that as more women entered surgery, biases would naturally correct. But again, this turned out not to be true. Instead, we found that the greater the representation of women in a specialty, the greater the opportunity to exhibit biases against female surgeons.

Dr. Fahima Dossa
Dr. Fahima Dossa

Part of the explanation for both findings is that these biases are often implicit. If an individual is asked, “What does a surgeon look like?” even today, often the mental representation conjured up is that of a man. Our society still holds men and women to social norms, or gender schema. Men are expected to be decisive, aggressive, commanding — qualities often thought to be possessed by surgeons — whereas, women are expected to be kind, nurturing, and compassionate. These schemas, in turn, influence our implicit sense of who is a competent surgeon.

The study talks about the concept of “homophily,” a tendency for individuals to associate with — and, in this case, make referrals to — people who are like themselves. How does homophily translate, in a medical scenario, into gender bias, disadvantaging female surgeons?
As you mention, homophily is the term used to describe the phenomenon whereby individuals who are similar along certain characteristics are more likely to interact with one another than dissimilar individuals. We see this around us every day — men are often friends with other men, women with other women, individuals from the same racialized groups often develop bonds.

In medicine, and surgery, this social phenomenon can implicitly contribute to inequity for women in surgery. Despite increasing numbers of women in medicine, men remain the majority. That means the majority of physicians referring patients to surgeons are men. If those men rely on feelings of kinship — implicitly or explicitly — when making referral decisions, they will naturally over-refer patients to other men. This is one explanation for why female surgeons receive fewer referrals and fewer operative referrals than male surgeons, even after accounting for their availability and time spent working.

What sort of threat does gender bias against female surgeons pose for patients? What impact can it have on patient access to care, or even patient safety?
Firstly, it’s important to consider outcomes. Another JAMA Surgery study by Dr. Chris Wallis examined the post-operative outcomes of male and female surgeons, and demonstrated that the patients of female surgeons had equivalent, and in some cases slightly better, outcomes than those of male surgeons. So, increasing referrals, and particularly operative referrals, to female surgeons does not compromise the quality of care received by patients. That is important to establish up front.

Knowing this, the surgical backlogs created by COVID-19 impress upon us the need to think about the ways in which our health care system is inefficient or inadequately serving patients. Our data show that there are likely a number of female surgeons who are being underutilized. These female surgeons can provide the highest quality of care to our patients. By continuing to undervalue and underutilize this segment of our workforce, we accept longer wait times and inefficient care for our patients.

Speaking of COVID-19, how might reducing gender bias against female surgeons help Ontario with its backlog of surgeries?
Currently, we work within a multiple queue system — patients are referred to chosen surgeons and wait in a queue to see that surgeon. In such a system, wait times can vary considerably for each patient, with some patients waiting much longer than other patients who are receiving identical treatments. This is particularly problematic in the presence of surgical backlogs because surgeons serving as a bottleneck limits our ability to make headway on the backlog, even if we have greater investment of resources.

Gender biases further exacerbate this issue, but also present an opportunity for improvement. Imagine an extremely hypothetical scenario, where male surgeons are receiving an overwhelming number of referrals leading to long wait times, and female surgeons are not receiving many referrals and so have nearly non-existent wait times. Clearly, an alternative system blind to the gender of the surgeon would equitably spread patients out among all surgeons, ultimately leading to more timely care for all patients. One way to build such a system would be to implement a centralized referral system. In such a system, patients wait in a single queue and are seen by the next available surgeon. Such a system reduces the gender bias we are seeing, helps to address wait times and helps us work through the surgical backlog.

How optimistic are you that we can turn the tide on the sort of gender bias your study looks at? What do you see as the way forward?
I think it can be a reality here in Ontario, but it is going to take focused action on the issue. Up until now, we’ve approached this with a passive mindset. We thought that adding women to the surgery specialty would solve the problem. It didn’t. The pandemic has revealed ways we can improve our health care system. It has revealed inefficiencies in how we do things, so we can focus on the changes we need to make. I’m optimistic that we can make change, that we can rebuild this system and make progress on this issue.