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Addressing Gender Equity and Diversity in Canada’s Medical Profession

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A good interpersonal relationship between a patient and provider - as characterised by mutual respect, openness and a balance in their respective roles in decision-making – is an important marker of quality of care. Unfortunately however, the patient-provider interface has often been described by clients as discriminatory, marginalising, abusive and mirroring the social stratifications of society at large. This holds true for both developed and developing countries. This experience of discrimination and poor quality care is even more marked for poorer, lower class, caste women and men and is also mediated often by other factors including ethnicity, religion and language group etc.

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Most of the efforts made to minimise bias in organisations has focused on controlling or eradicating the biases that exist in our minds. Implicit bias training is an example of such efforts. Testing for implicit bias via the Implicit Association Test (IAT)has become commonplace, and has risen in popularity along with implicit bias or diversity training

Despite the millions of dollars spent on administering the IAT and training people to act without bias, the evidence that this kind of training actually changes organisational outcomes is scarce. More commonly, diversity training (especially when done alone and not in combination with other organisational interventions) has produced a host of unintended consequences. It has been shown to be associated with reduced diversity, worsened behaviour toward minority co-workers, and the creation of the illusion of fairness such that those who claim to have experienced discrimination are less likely to be believed. Instructing people to avoid the use of stereotypes can paradoxically lead to increased activation of those stereotypes, and attempts to increase the awareness of stereotype prevalence can inadvertently normalise stereotyping and discrimination (such as, if everyone uses stereotypes it must be okay). Eradicating these innate human biases is difficult and likely to be impossible. Although educating people about these biases and providing education on how to recognise them is an important first step, we must go further to create systems and environments in which bias and stereotyping are either less likely to become initiated, or are prevented from resulting in discrimination even when they are active. The first myth that should be debunked is the idea that bias is a problem unique to only a few individuals: namely the racists, sexists, and bigots among us. However, research on the human brain and how it makes sense of the world suggests not only that all of us are biased, but that we must be biased to survive. Cognitive biases and heuristics are shortcuts that allow us to interact meaningfully with people, objects, and tasks without having to exhaust our insufficient attentional resources to decipher every sensory signal. Whenever you encounter a person, for example, your brain rapidly engages in a series of calculations to interpret that person's relevance to you by placing them within a social category.T he first automatic calculations regard age, race, and gender. Because of this perceptual primacy, gender has come to frame the way we see the world; it is an implicit or unconscious bias that serves as a foundation upon which stereotypes, expectations, and norms have been created. Social categorisation is an inevitable part of our perceptual experience, such that the stereotypes we hold about different social groups will alter our perceptions of, and reactions to, individual group members. Further, when it comes to devaluing women's contributions in masculinised settings, women can be just as biased as men, meaning that people of all gender identities can perpetuate gender bias in organisations. Rejecting the idea that only some people are biased is a crucial first step to personally engaging with the problem of discrimination so as to bring about change.

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The gender pay gap, defined as the difference between what men and women earn for roughly equivalent work, has remained a core challenge in employment equity despite decades of activist effort and the substantial movement of women into the workplace. The Canadian government is taking steps to address the issue broadly, but there has been little action thus far from health care leadership to address pay equity within the medical profession. In this article, we summarize evidence on the gender pay gap in medicine in Canada and abroad, and discuss common myths, likely root causes and possible solutions. We start with the premise that equal pay for equal work is a matter of fairness and is necessary for the profession to move from aspirations of gender inclusion to equity and justice for women. Gender is not binary; however, we focus on differences in pay between groups defined in the data as men and women (Vogel L., 2017). Currently, there is little research on the experiences of nonbinary physicians. In the broader Canadian workforce, the pay gap is larger for women who are Indigenous, racialized or newcomers, or are living with a disability

However, there are few comparable data in medicine, and discussing how the intersection of different identities may affect pay disparity is beyond the scope of this article. Numerous studies, mostly from the United States and the United Kingdom, have shown a clear gender pay gap among physicians. This effect is seen in clinical, research and environments. Inequities start at the early stages of a medical career, deepen with time, continue into retirement and affect lifetime wealth, with estimates as high as $2.5 million over a 30-year career. The pay gap in medicine persists after adjustment for factors like physician age, specialty, number of hours worked and practice characteristics. The limited data available in Canada suggest a similar situation. The proportion of women among Canadian physicians has grown rapidly, from 11% in 1978 to 43% in 2018. Yet data from Ontario show that women account for only 8% of the province’s highest-billing physicians (Biringer A, Carroll JC, 2012). Our own analysis of Canadian data, along with analysis done by others, suggest that some pay differences are driven by specialty but that there are also gender pay differences within specialties.

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In summary, gendered stereotypes and role expectationsi continue to have an impact in the field of medicine, where women face an implicit bias that can negatively affect their hiring, promotion, career development and well­being as well as their career choices and trajectories. For example, across specialties, medical learners have been shown to perceive women physician instructors to be less able as educators than male instructors

More broadly, physicians working in areas with strong gender expectations face implicit bias that increases their likelihood of experiencing negative evaluations from, or interactions with, patients, learners, colleagues and senior physicians.

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Csanady A. Ontario’s doctor wage gap: just eight per cent of province’s top-billing MDs are women. National Post [Toronto] 2016 Apr. 29. Available: https://nationalpost.com/news/politics/ontarios-doctor-wage-gap-just-eight-per-cent-of-provinces-top-paid-mds-are-women

Bogler T, Lazare K, Rambihar V. Female family physicians and the first 5 years: in pursuit of gender equity, work–life integration, and wellness. Can Fam Physician 2019;65:585–8.

Biringer A, Carroll JC. What does the feminization of family medicine mean? CMAJ 2012;184:1752.

Vogel L. Pay gap growing between family doctors, other specialists. CMAJ 2017; 189:E1300.

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