Equity: Facts and Future

We recently published a paper in Ophthalmology that featured a population-based evaluation of the differences in remuneration between female and male ophthalmologists compared with other physician specialty groups in Ontario, Canada, over three decades (1). We found that female ophthalmologists in a fee-for-service system had lower median payments than males despite their productivity based on the number of patients in their practice and the number of visits – and after adjusting for age and year of practice. Our results displaced the myth that lower pay is solely the outcome of less work. The same finding was observed amongst other specialty groups, including medical procedural, non-procedural specialties, and surgical – but the sex difference was more pronounced in ophthalmology (1). We are not the first to note these differences in remuneration. In fact, disparity in pay has also been noted for female ophthalmologists in New Zealand, where the pay gap between the sexes remains significant even when adjusted for hours worked (2). Although the true underlying reason for these discrepancies remains to be elucidated, some suggest that the disparity exists even within the first year of starting clinical practice (3).

Another interesting finding from our paper is that female specialists have a smaller representation in ophthalmology than most other surgical and medical specialty groups. And previous studies had already pointed out the under-representation of women in surgical specialties, such as orthopedics, thoracic surgery, and cardiology (4, 5). Again, the reasons remain unknown, but may be related to the lack of mentors and system challenges (6, 7). The finding is particularly alarming when we consider that most medical schools now comprise more women than men (8) – but that the proportion of women in ophthalmology and some other surgical specialties has not increased comparably.

We wondered if the influx of newly graduated female physicians and the delay in the time from graduation to practice may play a role in pay differences, but our age-adjusted model revealed a persistent gap in pay between the two sexes. Some of our previous work has shown that women make up 43 percent of all practicing family physicians in Ontario in 2013 compared with 20 percent in ophthalmology (9). As such, it is apparent that the majority of women are entering non-surgical specialties.

But the big question remains: what is driving the differences in remuneration between women and men? In our study, one striking difference was amongst top paid individuals. Men who were considered to be the most paid (higher than the 60th percentile) in ophthalmology in 2018 (the last year of the study) earned on average 17 percent (US$126,650) more than the top paid female ophthalmologists. In the same year, the top billing male ophthalmologists had a greater number of patient visits than their female colleagues despite having a fewer number of distinct patients. The male ophthalmologists belonging to this group also had 52 percent higher payments than other male ophthalmologists. As such, this cohort of top biller male ophthalmologists has a distinct practice pattern that disproportionately contributes to a large aspect of the healthcare billings in Ontario, Canada.

Some of the temporal trends in practice patterns of ophthalmologists, such as the frequency of patient visits with the rapid expansion of intravitreal injections after the approval of bevacizumab in 2005, may be driving these differences (10). Gender differences in practice patterns may be related to the inherent variations in subspecialty choices, practice set-up, and billing practices, which warrant further investigation. In a fee-for-service system under the single-payer healthcare system in Canada, those who spend more time on a patient consult for a complex medical or surgical case may be compensated less than those who see multiple routine patient visits during the same period of time. And that’s a key concept to bear in mind!

In pursuit of equity in medicine, we must all comprehensively consider the unique challenges and barriers for early-career women in ophthalmology and other specialties (11). Recent studies have suggested that female ophthalmology residents in the US perform fewer cataract operations and total procedures compared with their male counterparts (12). We previously found in a survey of Canadian ophthalmologists that women reported less operating time than men, with 51 percent of women operating less than two days per month compared to 36 percent of males (13). This was later confirmed in a study using billing data of Ontario ophthalmologists, where 68.6 percent of male compared with 57.9 percent of female ophthalmologists performed surgery – and, of those performing cataract surgery, male ophthalmologists had 1.7 times the volume of procedures compared with female ophthalmologists in 2013 (14). 

In addition to differences in payments between men and women, disparities have been shown in senior authorship on scientific publications, relationships to the medical industry, and grant opportunities (13, 15, 16, 17). In a survey of Canadian ophthalmologists, women believed that childbearing slowed or markedly slowed career progress, as compared with men (13). Studies on female physicians and surgeons have also noted the challenges they face in terms of delays in childbearing (18) and increased risks of infertility and pregnancy complications (19). Both real and perceived barriers regarding gender-based discrimination, lack of female role models, and challenges in balancing of personal and academic career in surgical specialties may be the major deterrents for recent medical school graduates (20, 21).

In an era when a growing number of women are choosing to enter medical school, addressing the barriers to progression for female physicians in surgical specialties will likely improve the appeal of ophthalmology as a profession for future generations of women (21).