Equal Work for Equal Pay : Annals of Surgery

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Surgical Perspectives

Equal Work for Equal Pay

Kelleher, Cassandra M. MD*,†; Chang, David C. PhD, MPH, MBA*,‡

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Annals of Surgery 277(2):p e247-e248, February 2023. | DOI: 10.1097/SLA.0000000000005734
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The article, “An Opportunity to Advance Workforce Equity: Surgical Referrals” by Drs Finn et al1 highlights that in efforts to promote equity in pay, promotion, and fairness in the workplace for women surgeons, we have overlooked one of the fundamental causes of the disparity, and that is work inequity. Although we can increase sex diversity by hiring more women, there cannot truly be equity or inclusion if there is not equal opportunity to work once hired.

Measuring work equity in medicine is difficult because we cannot simply measure the number of hours worked. Therefore, it has been common to assume that women surgeons lag behind male surgeons in pay, promotion, leadership positions, grant attainment, publishing, and so on because they take maternity leave and work less during the child-rearing years. So, it was not until recent studies examined distinct components of work that it become clear that there is a measurable discrepancy in work equity between male and female surgeons. Specifically, female surgeons are underemployed.

As Dr Finn and colleagues point out, women surgeons are sent fewer referrals than their male colleagues.2,3 This, however, is only the tip of the iceberg. Women are also sent fewer referrals that result in an operative procedure and are exponentially penalized for complications when compared with male surgeons.3,4 A smaller proportion of women surgeon’s cases require their advanced subspecialty training, and women struggle to develop a clinical niche upon which to build an academic career.5 Furthermore, women have been found to perform lower Relative Value Unit-generating operations in nearly all surgical subspecialties, even when availability, training, and seniority are accounted for.6–8 As a result, women are pushed to do more emergency cases and larger numbers of low remuneration cases to meet Relative Value Unit targets.5 Other workplace studies show that women are more likely to perform uncompensated “citizenship tasks” (ie, committee work and conference scheduling) than their male colleagues.9,10 All in all, these studies paint a picture of underemployment of women surgeons. And this has not improved over 2 decades.

Rigorous and innovative scientific methodology has also been applied to the assumption that female surgeons work less because of childbearing or child-rearing. In 1 study, female surgeons returned to the equivalent preleave operative volumes by 2 months after a maternity leave.11 Of note, this was the same rate at which all surgeons who took any kind of leave resumed preleave volume. Women surgeons at a large academic center were also found to be equally available for clinical work as their male colleagues when their proportion of the surgical workforce was accounted for.7 These data strongly refute the assumption that the above detailed work inequality is because of parenting.

Prior efforts to address sex inequities in the workforce have targeted the end results of work inequity, the visible consequences. For example, there are many programs in leadership training, negotiation skills, and networking for women. Although empowering women to become leaders is an important goal, these solutions have focused on the individual level, on the female surgeon herself. They have been successful because all surgeons who strive for leadership opportunities in academic surgery require these skills. However, caution is also needed in directing these skills training specifically to women, as it risks perpetuating “women as deficit” thinking, which suggests that women are inherently less capable than men and need to be “fixed” or “taught.” Another focus has been on the surgical leadership to increase transparency in compensation packages and to ensure men and women are paid equivalent amounts for equivalent tasks. This much needed change has a mitigating effect on gross inequities in surgeon’s salaries, but as women are unable to obtain equal work, these efforts have not been able to equalize take-home salaries. Therefore, we advocate for additional systemic measures to ensure work equity between male and female surgeons.

At the internal surgical department level, some considerations include monitoring for comparable case complexity and emergency case volumes and redirect referrals to colleagues with low complexity. Alternatively, financial incentives could be given to surgeons who redirect referrals to colleagues with low complexity. Placing rotating attending surgeons in multidepartmental clinics such that the surgeon in the clinic that week retains the new patients could also spread case volume and complexity more evenly. Succession/retirement planning is also a way to focus on work distribution. When surgeons reach an age at which they are no longer practice building, they should be expected to sponsor junior partners, who now often include women, to take on complex work and endorse referrals to the group rather than to themselves. But as Dr Finn and colleagues highlighted, internal interventions must be paired with externally directed interventions targeting referrals. These could include marketing campaigns to specifically promote women faculty directed at patients or at PCPs and specialists who refer to surgeons. Electronic decision support tools for referrals could also be designed to track and allocate referrals based on specifications set to ensure equitable referral distribution.

Although it is bad enough that consequences of work inequity affect individual surgeon’s earnings, promotion, and job satisfaction, the truth is that the consequences are far wider reaching. The long-standing inequity, and the suggestion that the woman herself is to blame, are particularly demoralizing and lead to attrition of women from the surgical workforce.12,13 This negatively impacts public health on multiple fronts. Women in surgery increase the diversity of surgical viewpoints, which improves the quality of patient care.14,15 For example, female surgeons are more likely to perform breast-conserving surgery for breast cancer than male surgeons, and thus helped to shift the standard of care away from total mastectomy.16 Female surgeons also led the fight against sex bias in drug development.17,18 In addition, women are poised to become the majority of the surgical workforce, with 50% of many surgical residency positions now obtained by women. Thus, these inequities in the workplace that hurt career satisfaction and trigger attrition of female surgeons could contribute to a surgical workforce shortage.

Despite the progress at diversifying the medical workforce, there is still a lack of genuine inclusion of women and measurable work inequity. In 1849, the first female physician in the United States, Elizabeth Blackwell, graduated from medical school where she was accepted as a prank. It took another 170 years, until 2019, for women to achieve 50% representation in medical school classes. Female chairs and professorships still lag far behind the 50% mark, and women in medicine make $2 million less over their careers than their male colleagues.19 One long overlooked cause for this inequity is the lack of work equity. It is time to recognize that equal pay, promotion, and leadership opportunities can only be achieved when women, in fact, have the opportunity for equal work.


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