Male Physicians Refer More Patients to Male Surgeons, Study Finds

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Male physicians disproportionately refer patients to male surgeons, a new analysis published online today in JAMA Surgery has found. This trend remained constant over the 20-year study period, despite more women entering surgical specialties.

“A number of female surgeons, myself included, had the sense that it was easier for our male colleagues to build their practices than it was for us — that referrals were harder to get for us,” senior study author Nancy Baxter, MD, PhD, a surgeon and head of the Melbourne School of Population and Global Health in Australia, told Medscape Medical News in an email. “Now we know it wasn’t our imagination.”

The new study was spurred by Baxter’s team’s prior research, which found that pay disparities are just as pronounced in fee-for-service compared to salary-based systems. One of the drivers of this gap was that, compared to their male colleagues, female surgeons had fewer opportunities to perform the most lucrative surgeries. One explanation for this, they thought, could be biased referrals.

To find out, researchers analyzed outpatient referrals to surgeons in Ontario, Canada from January 1996 through December 2016. The analysis included claims from surgeons in the following specialties: general surgery, neurosurgery, orthopedic surgery, plastic surgery, obstetrics-gynecology, ophthalmology, otolaryngology, and urology. All claims data was obtained from ICES, an independent, nonprofit institute that provides population-level administrative health data. Provider specialty, age, and years of experience were determined through the Corporate Provider Database.

The analysis included 39.7 million referrals to 5660 surgeons. Though male surgeons made up 77.5% of all surgeons, they received 87.1% of the referrals from male physicians and 79.3% of referrals sent by female physicians (P < .001). Along with receiving fewer referrals overall, female surgeons also received fewer procedural referrals than male surgeons (25.4% vs 33%, P < .001). Physician age and practice experience did not affect provider choice, and these differences did not wane over time as more women joined the included surgical specialties. After adjustment for patient and referring provider characteristics, male physicians were 32% more likely (95% CI, 31.8% - 32.2%) to refer to a same-sex surgeon; in contrast, female physicians were found to slightly favor (1.6% greater odds (95% CI, 1.4% - 1.9%) referring to female surgeons.

While these findings are not surprising, “it’s important that we are starting to put data behind what anecdotally a lot of people are starting to recognize in the system,” said Caprice Greenberg, MD, chair of the department of surgery at the Medical College of Georgia at Augusta University in Augusta, Georgia, in an interview with Medscape. She was not involved with research but co-authored an invited commentary on the study.

The fact that this bias did not dissipate over time was surprising, said Fahima Dossa, MD, a general surgery resident at the University of Toronto, Canada, and lead author of the study. While the number of referring female physicians increased over the study period, they found that from 2012 through 2016 — the five most recent years included in the study — women physicians had 5.1% lower odds (95% CI, 4.7% – 5.4%) of referring patients to same-sex surgeons.

“Despite our assumption that problems like this will naturally fix themselves over time as people become more aware or as more women enter surgery, our results actually refute those assumptions,” she said. “[We found that] the more women there are in a specialty, the more biased referrals become.” These findings also emphasize the engrained nature of gender bias, Greenberg said. “It highlights the point that gender bias is not a ‘men vs women’ issue; it’s actually a societal issue,” she noted.

Dossa and Baxter argue that systemic changes are necessary to reduce gender bias in surgery, such as more centralized approach to referrals. Rather than referring to an individual physician, a health system or institution could require referrals to a surgical practice. From there, a case would be assigned to the next available, equally qualified surgeon. This approach would not only address gender equity, but also help lessen surgical backlogs, Dossa said, by reducing the wait time by individual patients.

But efforts to combat gender bias in surgery should not be a one-size-fits-all approach, noted Greenberg. “Each system is going to be different,” she said, “so each system really needs to take a look at how access is gained and where there might be biases that that we’ve been blind to for a really long time.”

The study was funded by the Canadian Institutes of Health Research and the Physicians’ Services Inc Foundation. The study authors and editorialists have disclosed no relevant financial relationships.

JAMA Surg. Published online November 10, 2021. Full Text, Editorial

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