Over the past decade, medical school graduates have been nearly 50% female. In some medical schools, more than half of their graduates are women. This is in contrast to the mid-twentieth century, when a medical school graduating class typically had a handful of women. Or perhaps half a handful. While medicine is now filled with women, female surgeons remain scarce. Just over 10% of female physicians enter surgical specialties, and under 25% of all surgeons are women. While the fact that 1 in 4 surgeons are female surgeons is up from two decades ago, when it was 1 in 7, a recent study looked at what kinds of surgeries those women are doing. Turns out, it’s the simpler stuff.
A study published in the Annals of Surgery looked at what types of surgeries female surgeons and male surgeons perform. The authors, based at the Massachusetts General Hospital (MGH), Harvard Medical School, reviewed over 500,000 surgeries performed between 1997 and 2018. Of the 131 general surgeons, 20% of them were female, and these women performed just about 20% of the surgeries. If we left it there, it would seem like a pretty equitable arrangement. But looking just below the surface shows a clear discrepancy.
An entity in medical reimbursement called Relative Value Unit, or RVU, based on acuity, difficulty, as well as duration, is a measure of both complexity and effort of work required to complete a medical or surgical encounter. The RVU has become a commonly used measure of work effort in all medical specialties, and is often utilized to measure individual physician payment, especially for physicians working in large institutions. The MGH study compared the average RVU for surgeries performed by men to those performed by women. Over the two-decades of surgeries analyzed, male surgeons earned an average of 1.65 RVU per surgery more than their female counterparts, and over 110 RVU more per month.
The issue the authors of the study raise is not so much “equal pay for equal work,” but inequality obtaining equal work. The study data accounted for issues of seniority, availability, and years of training. It appeared that these issues did not factor in to the findings that female surgeons at the same level of training and same level of seniority perform less complex surgeries than do males.
Dr. Cassandra Kelleher, senior author of the study, Surgical Director of the Fetal Care Program and Neonatal Intensive Care Unit at MGH, and Assistant Professor of Surgery at Harvard Medical School, notes that this is neither a unique, new issue nor one that has shown many signs of progress. Her prior work showed that female surgeons also do fewer surgeries per year than male surgeons. Her recent work showed that when comparing types of surgeries, the surgeries performed by women were simpler.
While much of this data looks at over two decades ago, the recent study shows no movement towards equity. Why this is has several explanations. According to Dr. Kelleher, “the slow pace of academic promotion, pay inequity and inequalities in practice building have been attributed to...lack of negotiation skills, lack of advocacy, lack of leadership skills. So the ‘fix’ has been targeted at the individual surgeon level. We have been encouraged to take leadership courses, negotiation bootcamp and to avail ourselves to referring providers. What we have shown however, it that there are inequities in the systems in which female surgeons work that require attention at a level well above the individual surgeon. In addition, historically the ‘end result’ of employment patterns are measures- promotion, grant awards, salary; where we are measuring the actual components of employment that contribute to these gaps. As employment patterns have not previously been measured, there has thus far been no ‘need’ to fix them.”
Moving forward, Dr. Kelleher refers to the current obstacle as “under-employment,” meaning under-utilization of skills, versus “unemployment,” which is rarely, if ever, an issue for surgeons: “In addition to leadership training and negotiation training, let’s examine how we can fix the underlying system so that we can take the onus off of the female surgeons and physicians. Just like a college graduate working in Starbucks cannot fix his or her under-employment problem, we need to think systemically if we want to fix this under-employment for female surgeons and physicians.”