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Gender biases in medicine: Female surgeons get fewer referrals from male physicians, study finds

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TORONTO -

A new Canadian study has found that male physicians disproportionately refer patients to male surgeons over female surgeons despite both genders being equally qualified and experienced.

The study, published Wednesday in JAMA Surgery, analyzed nearly 40 million referrals to 5,660 surgeons in Ontario and found that the differences in referral volumes and types could not be explained by patients’ choices or by characteristics of the surgeon, such as age or experience.

Although male surgeons accounted for 77.5 per cent of all surgeons, they received 79 per cent of referrals sent by female physicians, but 87 per cent of referrals sent by male physicians from 1997 to 2016, according to the study.

The study found that female physicians were 1.6 per cent likelier to refer patients to a female surgeon, and male physicians were 32 per cent likelier to refer patients to a male surgeon, despite having access to equally qualified female surgeons.

As more women entered surgery over the study’s 10-year span, the authors noted that this number did not decrease.

The difference in referrals is a form of gender bias that researchers say needs to be addressed as it not only disadvantages female surgeons, widening the gender pay gap in medicine, but also puts up certain barriers to patients seeking help.

Dr. Fahima Dossa, co-lead author of the study and general surgery resident at St. Michael’s Hospital of Unity Health in Toronto, told CTV News that the data supports her experiences, as well as that of her colleagues.

"We have data to show that these are not one-off experiences and that they don't reflect who we are as individuals, but rather how women are being valued in surgery in Ontario right now and the across the country," Dossa said.

Gender bias in medicine isn't new. Other studies have shown that female surgeons earn 24 per cent less per operating hour than their male counterparts, and the new findings in Ontario help explain why.

According to the new study, the differences in referrals was surprisingly greatest in surgical specialties with the highest representation of female surgeons, including gynecology and plastic surgery.

Dr. Nancy Baxter, senior author of the study and a scientist with the Li Ka Shing Knowledge Institute of St. Michael’s Hospital of Unity Health Toronto, told CTV News that she always assumed that these differences were because she wasn't good enough or because her patients weren't happy with her care.

"Knowing that… it's an 'old boys' club' and the deck is stacked against women surgeons, it's not good, but at least you don't internalize it," Baxter said. "It's not you."

"It's bias and that's awful," she added.

Baxter says the "conscious mind" of a physician is thinking of all the reasons why they shouldn't refer a patient to a woman, but should refer to a man. She said there's "always an excuse" why not to refer to a female surgeon.

"When you objectively look at it, the woman and the man may have almost exactly the same outcomes, the same availability, the same patient satisfaction, but you always find some reason that you should refer to the man instead of the woman," she explained.

The study found that female family doctors were more even-handed in referrals, slightly favouring female surgeons.

"What's important to keep in mind as we frame these discussions is that these biases are not being manifested just by men, that both men and women in our study show this, both men and women do carry these biases," Dossa said.

Of the referrals female surgeons did get, the study found that they were often for less complex procedures or from patients who likely didn't need an operation at all. Baxter said these types of patients are less likely to make a surgeon money.

"I had lots of referrals for patients that were more complex problems that were unlikely to need surgery, and a lot less referrals for the patients that obviously needed an operation," Baxter said.

Dr. Elizabeth Shaughnessy, president of the Association of Women Surgeons and a professor at the University of Cincinnati, told CTV News that these difference in the types of referrals between each gender aren't obvious forms of discrimination.

"We're seeing it in its more subtle forms which is far more difficult to identify and eradicate, which is disturbing to us because as women surgeons, we certainly suspect that this has been going on for a while and this just helps to confirm certain suspicions," Shaughnessy said.

Shaughnessy said the new findings are important as they showcase "implicit bias."

"It may not have been even something that those particular male doctors were thinking about, but it might be the case that we have to change how we're doing things in order to best eradicate implicit bias in that context," she said.

The researchers behind the new study say this problem demonstrates the need for efforts directly focused on eliminating sex-based biases within medicine, including changing referral models so patients go through a central referral registry and are scheduled to be seen by the first available surgeon.

"You may not be referring to the doctor who can see the patient… or who can operate on the patient as soon as [possible] if one of the things you're taking into account is gender," Baxter said.

She added that these biases can create roadblocks for patients in need, and says a single-entry referral model would speed up care.

"It doesn't just hurt women; it hurts the health-care system and hurts patients too," Baxter said. "The 'old boys club' isn't good for patients."

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