How physician identity influences income

This episode of the CMAJ Podcast explores how physician identity can influence patient expectations, and how those expectations may contribute to gender, race, and immigration status pay gaps. The discussion builds on the CMAJ article “Family physician pay inequality: a qualitative study exploring how physician responses to perceived patient expectations may explain gender, race, and immigration status pay differences”.

Dr. Monika Dutt, a family physician, public health and preventive medicine specialist, and PhD candidate in health policy at McMaster University, explains how the study’s interviews with 55 family physicians across Ontario revealed patterns linking patient expectations to physician identity. She describes how gender and cultural background influence the types of visits physicians are asked to provide, and how these interactions may affect their earnings under fee-for-service models.

Dr. Meredith Vanstone, professor in the Department of Family Medicine at McMaster University, outlines how physicians adapt to explicit and inferred patient expectations and the income implications that follow. She discusses how these expectations are shaped by identity and why the resulting adjustments in care can lead to financial penalties for some physicians while improving patient relationships and trust.

The guests highlight how remuneration structures can either amplify or mitigate these inequities. They suggest that moving toward salary or time-based models could help reduce the impact of physician identity on income while supporting equitable, patient-centred care.

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Transcript

Speaker: 0:01

Dr. Blair Bigham I'm Blair Bigham. Dr. Mojola Omole I'm Mojola Omole. This is a CMAJ podcast. Dr. Blair Bigham Jola, this is an article that was flagged that you're particularly affected by. Do you want to lead us into it? Dr. Mojola Omole Is it because I'm a female? Is that why I'm particularly affected by this? Dr. Blair Bigham Well, not only female, but you're female, you're Black, and this is something that you care about as a surgeon. Dr. Mojola Omole Yes. So this was a great qualitative study that looked at how Ontario family physicians responded to patient expectations and that it might explain why there's a gender, race, and immigration status pay gaps. And it was able to do qualitative study across Ontario, so this is Ontario specific, and talking to family physicians with different genders, different ethnicities, and also whether they're IMGs or CMGs. And the results are, maybe for some of us who are listening, who are in these different groups, we would not find it surprising, but might be surprising for other people. Dr. Blair Bigham Like me, like some white dude who hasn't maybe thought about this as much as I should have. And I mean, certainly the pay gap between men and women has been explored, but it's been particularly interesting to look at how this article approached it to see if there were issues other than workload. You know, people traditionally say maternity leave or lower volumes. But this took a really interesting angle, and I don't want to give any of it away, but what we're going to do is talk to the authors and just have a chat about their study. It's titled, “How Ontario family physician responses to patient expectations may explain gender, race, and immigration status pay gaps.” It's a qualitative study. That's up next on the CMAJ Podcast. Dr. Mojola Omole Dr. Monika Dutt and Dr. Meredith Vanstone are two of the co-authors of a recent article in CMAJ examining how physician identity intersects with patient expectations and how that overall shapes physician pay. Dr. Monika Dutt is a family physician and a public health and preventative medicine specialist and a PhD candidate in health policy at McMaster University. She joins us from Sydney, Nova Scotia today. Dr. Meredith Vanstone is a professor in the Department of Family Medicine at McMaster University. Monika and Meredith, thank you so much for joining us today. Dr. Meredith Vanstone Thanks for having us. Dr. Mojola Omole So first, just off the top, why did you feel like this was an important study to do at this moment? Dr. Meredith Vanstone So this is part of a larger program of research. We've been working with some economist colleagues who, in very large data sets, identified that there are persistent pay disparities when you compare the pay that men physicians and women physicians get, when you compare the pay that racialized physicians and white physicians get, and when you compare the pay that Canadian-born physicians and those who've immigrated to Canada get. And so in their data analyses, there's lots of interesting descriptions of what these pay disparities are, but there aren't really any explanations. And in medicine, like this is an industry that we would expect there to be fewer pay disparities because everybody gets the same fee for the same service they provide. There's not these other mechanisms that we would typically understand to influence pay gaps, like your starting salary or what you negotiate or how merit awards are distributed. That doesn't apply to medicine, right? It's a negotiated agreement that all physicians are paid under. And so we wanted to try to better understand why these pay gaps exist and why they persist across jurisdictions, across specialties, when you control for the hours worked, like all of this data, we just wanted to understand what was going on. Dr. Mojola Omole How big were the pay gaps that you were seeing? Dr. Monika Dutt So we weren't actually measuring the gaps themselves. We were following up on other research that has shown these gaps to exist. What we have been seeing in general from other studies is that there tends to be, for example, about a 10% pay gap between men physicians and women physicians. And then we also see slightly less but similar pay gaps between, as Meredith noted, white male physicians in particular and racialized physicians. We also saw some differences based on whether people had immigrated or not immigrated to Canada. But our study did not actually crunch numbers. We talked to people to try to understand why those gaps are there. Dr. Mojola Omole So you had interviewed 55 physicians across Ontario. What kind of identities did those physicians bring to their practice? Dr. Meredith Vanstone So our 55 Ontario physicians were all family medicine physicians who had some sort of element of comprehensive care that they provided in their practice. And then we started by sampling people to make sure that we had diversity in gender, in race, in whether they did their training in Canada or abroad, and in whether they were born in Canada or immigrated here. As we started to analyze that data, as you do in qualitative research, you start analyzing as soon as you collect data and then you identify other things, other identities, other aspects that might be relevant. And so then we started to sample to make sure that we had physicians who had different caregiving roles in their life, who were located in different remuneration models, who were practicing in different geographical regions. And we asked them how long they spent on an intermediate assessment. And so we made sure that we had some people who said they were very quick with their intermediate assessments, in the middle, and some folks who took longer to do that A007 billing code. Dr. Mojola Omole So can you just explain to, like, I don't know the intermediate assessment, like, what that entails for a family physician? Dr. Meredith Vanstone So this billing code in Ontario is the bread and butter of a regular visit. It's used all of the time. So most people take about 15 to 20 minutes for this regular visit. Dr. Blair Bigham So in your paper, you sort of describe a bit of a framing, and I just want to set the stage for the audience here. So step one, patients sort of come with their own expectations of what's going to happen and what should happen that may be shaped by a physician's identity. And then the physician, step two, would perceive those expectations. And then step three, they sort of adjust the way the visit goes, their behaviour, the way they execute the visit. And then step four, you think that that might be associated with some of these financial disparities that we've noticed. Is that a fair way of summing up where your results ended up? Dr. Meredith Vanstone Can I give it another go at the framing? Dr. Blair Bigham Yeah, sure. Dr. Meredith Vanstone So the first stage is about perceiving those patient expectations. And sometimes these are expressed quite directly. So sometimes a patient will call and ask for an appointment with a particular physician and offer an explanation why. You know, I want to talk to somebody about birth control. Do you have a woman physician that I can have an appointment with? Or do you have a physician who speaks Mandarin or something like this? Sometimes the physician would impute what those expectations are, in part because they've worked with lots of patients who wanted to have a woman physician for the pelvic exam or something like that, and they would just infer that maybe this patient does as well. The second stage of our analysis is really describing what those expectations were, and they really ranged quite widely and quite broadly. The third stage is how the physician responded to those perceived expectations, so how they changed their practice, how they changed their interaction with the patient, how they restructured their work, all different kinds of responses there. And then the fourth stage is the income implications of the responses to the patient expectations. Dr. Blair Bigham That's super clear. So help me make a little leap here. There's both sort of pretty explicit expectations and then the more imputed or inferred expectations. Give me a few more examples of those expectations, and then tell me how a physician would actually respond to that. How would they change their practice? Dr. Monika Dutt So I can start. One of the main examples we looked at was gender. So as was just said, people, patients, may call specifically asking for often a woman physician if it's for something like an IUD insertion or a pelvic exam, and so they may specifically ask for a woman. Sometimes it might be related to the type of care that they may think that a woman physician will provide, for example, more time with them, more emotional support. So that might be more imputed. They might not specifically say that when they call, but that might be a reason why they are specifically asking for a woman physician. And then the physician, in turn, will respond to that. So they may book in the pap smear or the pelvic exam because they know that they are being asked to do that, at least partially because they're a woman and they want to accommodate that patient. People spoke to, in terms of financial implications, how some of those appointments may be poorly remunerated, and so when they do take on more of those appointments, they may end up having income implications for that. And then for the other example, if they are taking more time with a patient because that patient wishes to ask them more questions or has more vulnerable situations that they want to express to the physician that they feel more comfortable with, that might take more time. And in systems where time has implications for your income, you may not be able to see as many patients as you might like to because you are responding to that need of the patient and providing that care to them. But it means you may not see as many patients as you might like. Dr. Blair Bigham So there's a double whammy. You're being booked into maybe procedures or circumstances that may pay less, and you're spending more time than other physicians might. And so when you combine those together, you end up with financial consequences. Dr. Monika Dutt Exactly. And even people describe something like, you know, if they are pregnant, which is a lovely thing to talk about sometimes, but they also realize that if they get into a conversation about pregnancy, it could be a very long discussion about a patient who's excited for them in a way that takes up a large chunk of the appointment. And as much as they might like to have that discussion, they may not talk about their pregnancy because they don't want to take that additional time that someone might take with a woman physician versus a man physician. Dr. Mojola Omole So if you look at the various identities that physicians bring to work, how clear is it which one had the most, the biggest impact, or did one have the biggest impact? Dr. Meredith Vanstone I think it depended on the particular physician. Like everybody sort of told us stories about expectations that their patients had of them and the ways that they responded to those pertaining to their own, you know, intersectional, multiple identities. But for every physician, the way that they identified which identities were most relevant here was different. And we did notice that, I don't know if any of our, certainly most of our white participants did not talk about their racial identity as something which had bearing on the way that their patients formed expectations or communicated expectations of them or the way that they responded to those expectations. But all of our participants who were racialized in some way other than white, this was a pretty common topic of conversation, both in terms of how they related to people who were members of their same racial or cultural group and also in terms of the expectations that patients who did not share a racial identity had had of them. Dr. Mojola Omole And those who have the overlapping identities, I'm not sure if this would come out in a qualitative study, but was it like a compounding effect? Did like, you know, the physicians talk about, you know, when you layer in the various identities that it became compounded in terms of modifying their behaviour and then financial consequences? Dr. Monika Dutt Yeah, I'm thinking of one example, or actually a few who commented on this, that, you know, both being of the same racial and cultural background, but then also being a woman, added to this sense that someone talked about being seen as someone's like an auntie, and that might change the dynamic and people may kind of interact with you in a different way and potentially ask more of you because they feel that familiarity with you. And then again, that might take more time and more effort either to explain something or to change what some of the expectations might be, because it also came up that people might expect similar care to what they might have had in a previous country. And then you'd have to take that time to explain how care might be different here, because they have that sense of familiarity, both because of language and cultural background, but also being more of an auntie type of figure or someone that they feel that connection with. Dr. Blair Bigham I'm just going to speak frankly, you're essentially getting bogged down in a longer conversation than your counterpart might be. Dr. Monika Dutt Yes, although we do also look at the fact in our conclusion just that, is this in the end better care? So you do make that connection, you find ways to connect with your patient, you may be financially penalized for that, which is a consequence of how some physicians are paid, but potentially in the end, that does provide better care. And there is evidence around that when people have, you know, concordant genders or racial backgrounds that that can actually support care. But in systems, especially fee-for-service that people work in, it can end up bogging you down if you're trying to move along more quickly. Dr. Blair Bigham I saw Jola's facial expression when I said bogged down. And the reason I wanted to use that term is in the emergency department, I'd be like, oh my goodness, this is bogging me down, slowing me down. But we know that these types of conversations have very high yield when it comes down to building trust, for example, and building trust leads to following through on health advice. Sorry, Jola, it's exciting to me, these findings, like it really puts into perspective how a white male physician like me might frame my efforts at what I might gloriously call being efficient with actually providing less concordant care. Dr. Mojola Omole Another day. My question actually is, because I don't know if this is something that you looked at, but maybe just anecdotally from the physicians that you interviewed, but what is the cost on the emotional labour part? Because this is my daily life, where today, like, you know, either they're like, they think I'm one of their homegirls or they're like, oh, “You're so nice. Let me tell you about my bladder incontinence. And I'm like, you're here for your gallbladder. Like, so like, did you like, did you tease out? Were you able to tease out, like, if there was recurring themes around like burnout or the emotional toll of making great connections for your patients, but at what cost? Dr. Meredith Vanstone I think that we didn't ask about this explicitly, like really our interviews were very focused on income. But people still talked about this. And I think sometimes they talked about these relational connections with their patients as really positive aspects of the work. Like, remember, these are family doctors, right? And lots of people choose family medicine because they're looking for those sort of longitudinal trusting relationships. They see this as a valuable service that they're offering. But when it comes at the expense of your income or getting home in time for dinner with your kids or all of these other sort of time sequelae of taking more time, then it's not just the emotional labour of having these conversations, but it's also like the very real time labour and the energy that you're spending on that. So yeah, no measures of burnout. And in some places, I think people felt very positive about this and like it was a service that they were offering, that they could help their patients in a way that other physicians might not be able to or might not be willing to. So I think that the point Monika made earlier about this not being necessarily a negative thing, but really asking us to think differently about the type of care that people are receiving, the quality of care that people are receiving when they're given more time, that's super important. Dr. Monika Dutt And maybe just to add to that, we also asked people what they kind of saw in their colleagues and how they interacted. And again, it's this physician's perceptions. But we did have a story of someone talking about seeing their colleague who had a background that was a group that's been systematically marginalized. And they felt that that physician, they see them going above and beyond because they felt that physician felt an obligation to support patients of a similar background as much as they possibly could. And so that type of story came up. So it's a bit indirect to what you're asking, but I think that idea of feeling this obligation of needing to support your patients, especially from a particular background, because you've seen how difficult their life may be and you want to take that extra time, which has emotional as well as financial implications. Dr. Mojola Omole So what you're describing is something that's deeply structural. So how do we fix it? What are we going to do? Like, let's go. We're queens for the day. What is your edict to fix this? Dr. Meredith Vanstone Well, I mean, I think that we noticed something. So in Ontario, we have a whole bunch of different remuneration structures for family medicine, right? And some are fee-for-service, pretty traditional. And our respondents who are working in a fee-for-service model really felt extremely penalized when they took more time. This had very immediate impacts for their income. But models which were salaried, especially when they were working in practices which had an objective of working with patient populations who required more care, who required more system navigation, who required more help, this seemed to impact them less or they were less concerned about it. And so I think that that suggests to us that moving towards models which are time-based or salaried rather than a fee-for-service model could help alleviate some of these pay disparities. Dr. Monika Dutt Yeah, we've been thinking about the different type of remuneration models and how a study like this can help contribute to really incorporating how the identities of physicians may be considered within these types of remuneration models because we did have different types of models and people expressing how it may impact their income in different ways, whether it was capitation, whether it was fee-for-service, whether it was other types of models. So I think understanding the patient expectations as well as the identities that the physician may impact income and earnings can help influence what type of payment models are put into place. Dr. Blair Bigham It all comes down to the dollar. Dr. Meredith Vanstone I've got one more little thought, and that was earlier, I think Monika gave a nice story about the IUD insertions and the pap smears. And when we heard that, you know, chatting with other physician friends in different provinces, we heard a lot of surprise because I guess in other provinces IUD insertion is remunerated quite well. So then we did some double checking, like really like when they're talking about this, like what really is going on here and found that in Ontario it is remunerated at a very low rate that's different from many other provinces. So some of your listeners in Nova Scotia or British Columbia or who are working in other payment models might hear that example and think like, what are they talking about? IUD insertions, like it's remunerated fine for the equipment that's used for the time that's required. But this is something that Ontario in particular needs to catch up on. Dr. Blair Bigham Interesting. Thank you so much for joining us. Dr. Mojola Omole Thank you guys so much. Dr. Meredith Vanstone Thank you so much for having us. It's a really great opportunity to talk about this important topic. Dr. Mojola Omole Dr. Monika Dutt and Dr. Meredith Vanstone are two of the co-authors on the article in CMAJ titled How Ontario family physicians respond to patient expectations may explain gender, race and immigration status pay gaps, a qualitative study. So Blair, this was more surprising for you. So I'll let you take the floor first. Dr. Blair Bigham Sure. I guess it's interesting to hear sort of what this study has found in terms of the perspective of how having a certain identity as a physician leads to certain expectations of patients, maybe certain expectations of colleagues, and that that can really affect your workflow and make it different from my workflow. I found that a very interesting angle on this well-known top line problem, but a more nuanced approach to explaining why it is. And so then, of course, I'm curious, you know, maybe in your own words, Jola, like how does this affect you when you're running a clinic or trying to get through an operating list in a day? Dr. Mojola Omole So not so much in the operating room, although there are expectations of behaviour that is different for cisgendered men versus cisgender women and also based on ethnicity. But in terms of clinic, for sure, like there are different expectations that I feel and pressures that I feel being a female surgeon, being someone who identifies Black as Nigerian and that, you know, what are patients' expectations? Patients do expect us to be really friendly, to spend a lot of time, to not be, you know, not to be short, to explain. And I do think that one part that was really interesting was when there's ethnic concordance, how you have to go the extra mile, which I do think that is a big cultural expectation that people have, is that, you know, in certain cultures, obviously not all cultures, that you have to behave a certain way. And as they made clear and you made clear, is that this is the best way to practice. Like, this is good practice. This is how we deliver high quality patient care that meets the patient where they're at. However, that comes at a cost, and that is the financial cost to some of us. Dr. Blair Bigham So if the observation then is these extra time units, we'll say, being spent in these circumstances is actually the way we want to practice and not an expectation that is unfair that you're trying to meet, I guess the next question is, how do we move our system more in that direction so that everybody feels that they have that ability to slow down and spend time where patients might expect it or benefit from it? Now, of course, you know where I'm going with this is in our current model, speed is valued above quality. Speed is valued above time and trust building and extra communication. So I guess the question is, like, is the answer simply to move away from fee-for-service models towards salary models, or is that going to lead to maybe another can of worms that I haven't thought about? Dr. Mojola Omole So I can't answer that question because I do think it's specialty-based. What I would say is, instead of asking some of us to work a certain way to provide good care, why don't we ask all of us to work this way to provide good care? We should make sure that everyone feels comfortable being able to go to, whether you're a male, even if there's no ethnic concordance, they should always feel comfortable and they should always feel heard in those situations, too. Because putting the burden on certain groups, yes, there's also the financial burnout, but there's also the emotional toll of it. It's a lot of emotional work that we're asking one group to carry because while this is the most efficient, I wouldn't even say efficient, this is the fastest way to get through because efficiency means that there's actually quality associated with it. This is just saying this is just the most speedy way to get through your day and to see as many patients. Dr. Blair Bigham And what do you think about this idea that there's, like, cherry-picking, that somehow the tougher cases or the cases that require more trust-building are sort of punted to women or minorities? Do you see that as well? Dr. Mojola Omole Of course. Like, it happens all the time. I always joke when I get a certain referral, I'm like, wait, are they Black? Is that why you sent me? Like, is that why you're asking me to come and help take care of this patient? That always happens. And I'll be honest, I'm also guilty of it, too. If there's a certain patient that I need to refer to another specialist that needs a little bit more hand-holding, that needs that slow build of trust, I have a list of people I would send them to, and on that list, it's all women. And to go even further, it's all women of ethnicity. So I'm also guilty of it. Dr. Blair Bigham Well, I don't know if you're being guilty of it or if you're just innocently trying to work around a system that isn't working for everyone. Dr. Mojola Omole I'm not innocently doing it. I'm purposefully doing it. But, you know, at the end of the day, I mean, I always send a note first and say, hey, I'm sending you this patient. I am so sorry, but this is the reason I'm doing it. So just so that they also know that there's an awareness, because I do think once I'm aware of it, I'm like, OK, sure, fine. So you kind of mentally prepare yourself. And maybe that's part of it, too, right, is that there needs to be preparation in our system that we do that. I don't know if the answer is a salary model. I think there's a lot of benefits to a salary model. I think we all should have a basic income as physicians. Like, I shouldn't make more than a psychiatrist. We both did five years of extra training after medical school. Dr. Blair Bigham Interesting. Well, now we have some qualitative data to back up, certainly your experiences, and what sounds like the experiences of far too many physicians. That's it for this episode of the CMAJ Podcast. The link to the study is in the show notes. Please follow or subscribe to us wherever it is you download your audio. It goes a long way to helping us get the message out. You can also share or rate or review our podcast. That helps bump us up in the charts. The podcast is produced for CMAJ by Neil Morrison at PodCraft Productions. Catherine Varner is our deputy editor of the CMAJ and senior editor of the podcast. I'm Blair Brigham. Dr. Mojola Omole And I'm Mojola Omole. Until next time, be well.