Potential gender remuneration gaps in anesthesiology

To the Editor,

We thank Drs Byrick and Craig1 for their insightful response to Dr. Mottiar’s letter regarding gender disparity and the lack of representation of female Canadian Anesthesiologists’ Society award recipients.2 While we agree with much of Drs Byrick and Craig’s letter,1 several aspects warrant further discussion. For example, although the Ryten report¹ states that female anesthesiologists between 30–39 yr of age “worked 70% as much as men did,” we challenge the notion that working equates to billing. If one takes into account the various remuneration factors, including billing, the gap may be even larger than originally stated. Although the gender gap between male and female physicians is well documented, the reasons behind it remain poorly understood.

In the United States, female anesthesiologists have a lower remuneration than their male colleagues, even after controlling for hours worked, age, and specialty.3 In Canada’s fee-for-service model, several factors may lead to lower pay for similar work. For example, females have been shown to spend more time per patient,4 which may reduce billings over the same time period. In addition, females may take on a disproportionate amount of non-clinical, unfunded roles such as teaching, and female anesthesiologists may be discouraged from undertaking training in highly compensated subspecialties. For example, female anesthesiologists do proportionately fewer cardiac/vascular cases and more pediatric cases than their male colleagues.5 Even subtle biases in operating room assignments can lead to disparities in income over time.

Drs Byrick and Craig speculate that females work less in their child-rearing years, leading to fewer opportunities for leadership development than males.1 Although males are engaging in an increasing proportion of childcare and household responsibilities since the 1980’s,² females continue to shoulder a disproportionate burden, which likely drives a reduction in clinical workload. For similar reasons, females may be discouraged from taking on leadership roles that involve frequent after-hours meetings; Dr. Byrick points out that as females return to work, they remain clinically oriented whereas males are moving to leadership positions. We agree that females should be supported through increased flexibility in work schedule, including in their leadership roles, and further advocate that male anesthesiologists be offered the same opportunities.

Similarly, we agree that our current leaders must “ensure that all younger anesthesiologists gain leadership experience during early career development,” including female anesthesiologists, although this is but one aspect of a complex problem. Even when females do take on leadership positions, they may face additional scrutiny and risk due to the glass cliff phenomenon (i.e., placed into leadership positions that are known to fail or have a high probability of failing).6 Importantly, the data from the Ryten report showing that female anesthesiologists generate lower billings than their male colleagues early in their career must be interpreted cautiously. The complex reasons behind gender disparities in billing, work product, and anesthesia leadership require further rigorous study to identify effective strategies.