An Opportunity to Advance Workforce Equity: Surgical Referrals : Annals of Surgery

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Surgical Perspectives

An Opportunity to Advance Workforce Equity: Surgical Referrals

Finn, Caitlin B. MD*,†,‡; Guerra, Carmen E. MD, MSCE‡,§; Kelz, Rachel R. MD, MSCE, MBA, FACS†,‡

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Annals of Surgery 277(2):p e245-e246, February 2023. | DOI: 10.1097/SLA.0000000000005503
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The surgical community has increasingly recognized the negative effects of unconscious bias on female surgeons throughout their careers.1 In response, many have called for action to improve the experience of women through mentorship, sponsorship, thoughtful family leave policies, and transparency in the promotion process.1 These efforts are all important and necessary steps toward achieving gender equity in surgery. However, an emerging body of literature suggests that unconscious bias may have insidious effects that are overlooked by current efforts of surgical departments to promote fairness in the workplace.

At the center of the discussion on workplace equity is the right of all surgeons to have the opportunity to build robust clinical practices that utilize the full scope of their credentials and ability. This requires support from colleagues outside of surgery in the form of patient referrals. When bias influences how referring physicians direct their consultations, surgeons’ clinical productivity can be affected with downstream consequences on compensation, promotion, and job satisfaction.

Unconscious bias impacts how physicians interact with each other across specialties through several mechanisms. Homophily, the natural tendency to associate with others based on similarity, drives physicians to consult others who resemble themselves, often to the detriment of female surgeons.2 Strikingly, a male physician has 32% greater odds of referring to a male surgeon when selecting between surgeons matched on characteristics aside from gender.3 It should be noted that male surgeons display some of the strongest homophily when referring their patients to other surgeons.3

Patterns of gender bias in referrals are prevalent among referring physicians. In large studies of referral patterns using administrative claims data from Medicare and Ontario, Canada, male and female referring physicians disproportionately send their patients to male surgeons,3,4 resulting in fewer patients referred to female surgeons. For example, a study of surgical referrals at one large, academic institution demonstrated that female surgeons saw 5.4 fewer new patient referrals per month after adjustment for specialty, experience, race, and year.5 Beyond the number of consultations, gender bias also exists in the case-mix and complexity of patient referrals, with different types of patients referred to male and female surgeons. Patients referred to female surgeons are commonly less complex and less likely to require an operation.3 Given similar outcomes between male and female surgeons,6 disparities in referral patterns appear to be driven by unconscious bias rather than evidence.

Beyond homophily, referring physicians often believe that they can appraise the skill of their colleagues accurately and fairly. To the contrary, it has been shown that surgeon performance as assessed by reputation is not predictive of actual risk-adjusted outcomes.7 Performance bias leads physicians to underestimate women’s performance and overestimate men’s performance. Similarly, attribution bias causes referring providers to assign female physicians less credit for accomplishments and more blame for mistakes. For example, if a mutual patient suffers a postoperative complication, referring physicians disproportionately decrease future referrals to the surgeon if they are female,4 suggesting that they blame the surgeon for the adverse outcome. The referring physician also appears to generalize their appraisal to women in general, sending fewer patients to uninvolved female surgeons in their referral network.4 Notably, changes in referral patterns are not observed after a complication if the patient’s surgeon is male.4 These data suggest that referring physicians may attribute a suboptimal outcome to a lack of technical or clinical skill if the consultant is female, but not male.

Biased referral patterns inadvertently harm both surgeons and patients. A surgeon’s compensation and career advancement often depend on clinical productivity. For many surgeons, clinical productivity is intimately related to whether the surgeon can recruit a robust network of referring providers. In the current system, surgeons rely on their own efforts or the goodwill of a senior partner to build their practices, both of which are vulnerable to unconscious biases. With fewer opportunities to care for patients, women must strive harder than men to build a reputation among their referral network, which is in turn required to receive referrals. In addition, women who receive fewer elective referrals may be pressured to supplement their surgical volume with emergent and urgent cases through the call system, resulting in disruptions to the many other roles disproportionately filled by women. These barriers are often even greater for physicians who experience intersectionality, such as women who are also under-represented minorities.8 The self-perpetuating nature of gender bias in referrals may explain why the problem has not improved over the past 20 years,3 despite increased representation of women in surgery and efforts to support career development. Until women are treated fairly by their colleagues through equitable referrals, disparities in pay and advancement will continue to disadvantage female surgeons.

The underutilization of female surgeons deprives patients of a capable and essential workforce. Female surgeons provide outcomes equivalent to those of male surgeons,6 and may even offer better outcomes for certain patients.9 For example, female patients treated by male surgeons have a higher risk of postoperative complications and death than those treated by female surgeons.9 Male patients have comparable outcomes when treated by surgeons of either gender.9 While the reasons are likely multifactorial, female physicians may provide more guideline-adherent, evidence-based, and patient-centered care and communication.10

It is time for medicine to acknowledge the important roles that female physicians play in patient care. Referring providers can improve patient care by broadening their mental model of a physician and assessing quality through outcomes rather than superficial characteristics. Referring physicians should consider training, experience, and measured outcomes to identify the best physician for each individual patient based on their medical and social needs, discussing these considerations with their patients when they select a surgeon.

Departments of Surgery should investigate referrals within their own system to evaluate whether unconscious biases may be inadvertently harming the clinical productivity of their female surgeons, adjusting for experience and specialty choice. Before hiring new faculty, the department should ensure that a reasonable clinical demand exists, and that current faculty are satisfied with their clinical volume. Once hired, senior faculty members should sponsor their junior colleagues by facilitating introductions between new surgeons and their frequent referral partners and distributing cases according to interest and ability. Surgical residency and fellowship programs should teach their young surgeons strategies for building and maintaining a robust referral practice, including networking with other specialties, effective communication with referring physicians, and strategies for marketing expertise.11 These skills are all essential for building a satisfying clinical practice but rarely addressed in surgical education.

Institutions should consider transitioning from consults directed toward individual providers to those directed to a group practice or department, which may encourage a more equitable distribution of patients across providers. Administrative assistants who coordinate referrals can be trained to direct new patients to the surgeon most qualified to address the patient’s individual needs. A single entry-referral system may better allow surgeons shape their patient panel to conform with personal interests and expertise while equitably sharing the responsibilities for unplanned cases. The use of structural processes, such as group referrals, along with data and objective criteria to aid in the selection of consultants will advance workforce equity and improve outcomes for our shared patients.


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10. Tsugawa Y, Jena AB, Figueroa JF, et al. Comparison of hospital mortality and readmission rates for Medicare patients treated by male vs female physicians. JAMA Intern Med. 2017;177:206–213.
11. Wang TS, Beck AW. Building a Clinical Practice. Switzerland: Springer; 2020.

referrals; equity; women in surgery; unconscious bias

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