Physicians’ perception of their patients’ expectations is a key factor influencing the amount of money they earn, according to a study of family physicians in Ontario.

The finding may explain the persistently lower incomes for women, racialized, and immigrant physicians that have been noted for decades, according to the authors.

“There’s a large literature about pay gaps in all kinds of industries, but not in medicine, because most physicians in Canada are paid through a standardized pay scale,” senior author Meredith Vanstone, PhD, professor of family medicine at McMaster University in Hamilton, Ontario, told Medscape News Canada.

“You would think that this is an industry where these pay gaps wouldn’t exist. In other industries that have pay gaps, you may have negotiated a higher salary, or the gaps are due to subjective things that do not apply to medicine. In our study, we wanted to understand why these pay gaps exist in medicine, even though fees are standardized,” Vanstone added.

The study was published online on November 17 in CMAJ.

Perceptions and Pressures

The investigators interviewed 55 family physicians of various genders, races, and immigration statuses. The interviewees also spent different amounts of time on their typical intermediate patient assessments.

Physicians perceived patients to have different expectations about the way that physicians of different genders deliver care. These expectations related to the services offered and the provision of emotional support, among other things.

Women physicians perceived strong expectations that they provide more time, emotional support, and holistic care than their male colleagues. Gendered expectations placed additional pressure on women physicians to extend face-to-face time with patients, address all issues within a single visit, provide comprehensive counseling and education, engage in social talk, and ensure that patients felt heard.

The physicians in the survey also reported that patients often sought out gender-concordant physicians dealing with things like pelvic examinations, menopause, pregnancy, erectile dysfunction, and prostate exams.

This preference for gender concordance influenced the type of care physicians were expected to provide. Women physicians reported frequently performing intrauterine device (IUD) insertions and Pap smears, and some men physicians reported that their women patients scheduled these procedures with their women colleagues.

“All the females [patients] found out that I was a female provider and rushed to book their Pap smears,” a South Asian woman physician told the researchers.

“I’ve had patients tell me that they specifically booked with me because they know that I’ll take longer with them, or that they feel heard, or that they don’t feel rushed, or I’ll deal with more than one issue,” a White woman physician said.

Another White woman physician said, “People will ask for females because they will say to me, ‘Because they listen better,’ meaning they spend more time, right?”

More time spent with a patient means less income for the physician. One physician, a White male, stated, “I have had many patients who are due for a Pap smear and say to me, ‘I would be more comfortable with a female,’ and I struggle with that, because, you know, I am well aware that female physicians get inundated with Paps and IUD requests and that they take more time, they take more resources, they’re not remunerated as well as they need to be. And so that eats into their earning potential as well.”

Another White woman physician said, “We all do IUD insertions…it’s inside the basket primarily compensated through capitation payments, so it’s a 10% fee [portion of fee-for-service fee], so it’s like $4, like it doesn’t even pay for us to clean the tray.”

The survey also found that in culturally discordant patient relationships, physicians may spend more time on patient education to prove their competency or medical expertise and gain patient trust.

A Black woman physician said, “I think if you have to spend more time getting the patient to buy into what you’re saying and that you actually are competent to be giving them care, then you have to kind of take more time. You can’t just breeze in, breeze out, do your thing, and then leave, believing that the patient is listening to you and respects your messaging. So, that takes more time. Or sometimes patients will then come back for another visit to try and sort of say, ‘Can you explain this again because I don’t know that I agree with it,’ and that’s fine, but it also means that if you don’t fit their mold of what a doctor is, you spend more time convincing them that actually x, y, and z are not this condition, and this is why.”

This research may be useful for negotiations related to physician pay, Vanstone said.

“This study provides evidence that when physicians try to meet the expectations of their patients, it takes a longer amount of time. It ends up requiring more work that is not remunerated,” she said.

New Model Needed

Commenting on this study for Medscape News Canada, Rita K. McCracken, MD, PhD, assistant professor of medicine at Simon Fraser University School of Medicine in Surrey, British Columbia, said, “We knew women were getting paid less, the gender pay gap was real, and this paper gives us a better understanding about why we have that gender pay gap that we have been seeing for decade after decade.”

McCracken suggested that system-level changes are needed. The authors clearly illustrate that “whittling down” medical interactions into individually compensated components allows the pay gap to persist, she said.

“What we really need to be doing is looking at a funding model for physician work, like a salary, that more accurately represents the work and what it entails. We would never think of asking teachers who need to form a relationship with students in the classroom to be paid per student per lesson. That would be ridiculous. We should be looking for a model that compensates for the relationship-based, longitudinal work that family physicians are doing,” McCracken said.

The study was funded by the Canadian Institutes of Health Research. Vanstone and McCracken reported having no relevant financial relationships.