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- [00:01]
A
This episode is brought to you by Progressive Insurance. Fiscally responsible financial geniuses, monetary magicians. These are things people say about drivers who switch their car insurance to Progressive and save hundreds. Visit progressive.com to see if you could save Progressive Casualty Insurance Company and affiliates. Potential savings will vary. Not available in all states or situations. Foreign.
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Welcome to the you are not broken podcast. I'm your host, Dr. Kelly Casperson, a board certified urologist, thought leader, and conversation starter on midlife living, hormones and sexuality. Enjoy the show. Hey everybody. Welcome back. What if I told you that your chances of surviving surgery could depend not on the hospital or the technology, but on the sex of your surgeon? It sounds unbelievable, but here's what the data says. Patients are less likely to die when their surgeon's a woman. And get this, One study showed 30 day mortality was 12% lower for patients treated by female surgeons. Another study found that female patients treated by male surgeons had significantly worse outcomes, including higher rates of death and complications. And what's even more shocking, the research shows the same pattern with anesthesiologists. Female anesthesiologists are associated with better patient outcomes too. So what's going on here? Is this communication style, unconscious bias, training differences, or something else entirely? So today we're digging into the data and the human stories behind it with Dr. Christopher Wallace, the lead researcher behind these multiple landmark studies. So get ready for a deep dive into what your doctor's gender might be telling you and why it could save your life. Welcome to the podcast, Dr. Wallace.
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A
Thanks so much for having me.
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B
You're a urologic oncologist and you practice in Toronto. How did you get into outcomes based upon gender?
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A
Yeah, this is a great question. So the first paper that we published, I was actually a resident when we worked on this project. And it came a little bit by happenstance. I was building a big cohort of patients to look at a variety of questions around the idea of how we provide surgical care and how we can maybe provide surgical care in a better way. And around that time is when the New Yorker was doing all those covers, I look like a surgeon. And so I thought, you know what, why don't we try and put some data to this sort of gestalt feeling. And so we did this paper. I think I was a PGY4 resident at the time, and that's the one we put out in 2017 that showed if patient had a female surgeon, they were less likely to die or have major complications in the first 30 days after surgery. And then it's all kind of snowballed from there. We've now got close to a dozen papers trying to dig into it, understand it a little bit better, make sure it's not a one off observation that just happened by chance, and hopefully go from observing things to understanding things.
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B
Yeah, I think you've, in the amount of papers you've sent me is like you've time tested this now by looking at multiple countries, massive data sets. These are millions of surgeries, so it's not like Atlanta, Georgia has this issue, but it's like multiple countries, multiple surgical specialties, massive data sets. So you're not like these people were trained differently or something like that, really trying to suss out like if this was a mistake that you found this, you're going to realize that. But we're at the point now where your research papers have meta analyses and so for people to know what that means.
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A
Yeah, so exactly. So we started off, you know, with one study about like 1.2 million patients in Ontario. And then we wanted to be sure we weren't finding something spurious. We built a two and a half million patient cohort of Medicare beneficiaries from the US and then a variety, a variety of other cohorts. And we first started off in surgery. And so now there's about eight or nine papers across a variety of surgical contexts that have looked at this. And then we expanded beyond that. So there's studies now, as you alluded to in anesthesia, some of our collaborators have looked at this in the general internal medicine space. There's been some work looking at this in the emergency medicine space. And when you put it all together, the studies essentially all point in the same direction, which is a small but significant benefit in terms of patients outcomes when they have a female surgeon. So we had a meta analysis which is essentially a statistical way of combining studies. And so we put together these studies both within the surgical group and then looking at them across all aspects of medicine and found that very consistently we're seeing about a 5% reduction in the 30 day mortality rates for patients who have a female surgeon relative to a male surgeon in our cohorts. We've looked beyond outcomes like 30 day mortality to look a little bit more generally. But that's the outcome that's able to be most consistently examined across all the different studies that have been performed.
- [04:48]
B
Your like, evolution, because you've been doing this for a while now, like this is going to be your life's work, basically is like trying to suss this out. If you, if you Want it. But it's like, were you surprised? Are you now not surprised? Like, what's your evolution through this journey of, like, more and more data saying you guys are significant?
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A
Yeah. So I started off and my theory was going to be that I would show that there was no difference between male and female surgeons, that you can get an equally good outcome regardless of your surgeon's sex. And that ought to be rational enough to support that whole notion at the time around, I look like a surgeon and women belong in medicine and belong in surgery. And that was my starting hypothesis. I would guess by the time we got to the third paper, it was a consistent trend. And so it doesn't surprise me any longer when we see these results, we see a new cohort, we look at a new clinical context, and we find consistent results. I'm not surprised anymore. But now it's for me, going beyond observing that and documenting this phenomena to try and understand it a little bit better.
- [05:52]
B
What do the naysayers say? What do the haters say?
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A
You know, the way I look at this is phrased best by Tom Verghese, who you may know is a thoracic surgeon in Utah and online. He said that our work is essentially like an ink block test, particularly for male surgeons, which is to say that what you see as you read our papers says much more about who you are than what the paper itself says. So I would say there's three groups that are worth.
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B
That's nice support.
- [06:20]
A
It is. It's very good. So I think there's three groups. Number one, almost unanimously, female surgeons I interact with feel validated. That would be the most common response I get there. Then there are two groups of male surgeons. One of them takes it in the way that I hope people in general will. And the way that I've tried to approach it was essentially an opportunity for introspection and maybe understanding some root cause differences such that we can practice differently and improve our outcomes. And so, you know, fundamentally, I don't believe it's the presence or absence of a Y chromosome that affects a patient.
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B
Right. Like the ovary is taking all the credit.
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A
Exactly. And so, I mean, I think when we step back to give context, I'm the father of two daughters. We know from, like, birth, maybe a year old, that women are socialized differently than men. They behave with their peers, they behave with their parents, other adults differently. And so it's not surprising that you get to be a surgeon and men and women are going to behave a bit differently. And so to me, that's the obvious explanation, we can dive a little bit more into that later. But to circle back to the question, what's the third group? So the third group of men are the ones who don't take that moment for introspection and instead get defensive. And that manifests in a variety of ways. Our first study, it would be the epidemiological observation that association doesn't equal causation. Maybe it's a one off observation. And then you get remarkable consistency. You get not just the same direction, but the same magnitude of effect of across clinical context. And then they say, you know, it must be residual confounding. So, you know, there must be some underlying cause. It must be that the female surgeons get the better cases. And so I think, to provide a bit of context to that comment, some great work by one of my colleagues here, Fahima Dossa, who's a general surgical oncologist, looked at referral patterns in surgery. And so what we see is that female surgeons in general get fewer referrals than their male colleagues in general. And then on top of that, among the referrals they get a smaller proportion are operative.
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B
Validate that 100% in my practice.
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A
So, you know, in urology, there's the easy slam dunk. Someone sees a small kidney lesion on an ultrasound and they need to come for a partial nephrectomy. That's a slam dunk, easy referral, easy or booking. And then there's the undifferentiated voiding symptoms. No tests are abnormal, but the patient is miserable. And those take time and effort and don't really lead easily to procedural interventions that surgeons all like to perform. And so the idea that women would somehow be able to cherry pick all these easy and favorable operations out of this dearth of operative referrals is just a step too far to be believable. And so I think this idea of residual confounding doesn't hold water. But the question is to take a step back. It may be that the patients women operate on are fundamentally different than those that men operate on. Not because there's some bias in who gets to the female surgeon, but a different way in which the female surgeon practices and differences in terms of risk tolerance or judgment making, shared decision making, that changes the patients who actually get taken to the or.
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B
Yeah, or maybe optimizing them before they take them to the operating room.
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A
Exactly.
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B
For people who don't know what that means, like is diabetes control, do they have social support at home? All the things that we know lead to better outcomes.
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A
Absolutely. And I think there's this immediate instinct in surgical outcome research to assume that we want to look at the things that are happening in the OR and think that that explains why we get different outcomes. But the reality is that being a surgeon is so much more than, like, operating and cutting and sewing. And so your decision making during and after surgery, all of that comes into play. And that's all part of surgical practice that isn't technical. And so I think we need to consider all those other potential aspects of surgical care as part of that care package that men and women may be doing differently.
- [10:28]
B
Yeah. How do you suss out the possibility? Because I agree with you. It could be they're literally practicing different and you're finally picking up that the difference makes changes. Second possibility is what it takes for a female to go to medical school, then what it takes for a female medical student to actually go into surgery is maybe those are the Army Rangers instead of the, like, whatever the recruits that are, you know, coming from the work fair or something. Not to downplay the average medical student and resident. I'm not saying that. But what I'm saying is, is there something possibly you've weeded out any sort of average woman to become a woman who is in surgery? Because there's so many barriers to be that. That is there something different there? And how would you test for that?
- [11:14]
A
Yeah. So I can't prove this to you, but I want to give you a little thought experiment. So let's say that, biologically speaking, by the time you hit age 25, male and female medical students are equally predisposed to be great surgeons. And let's presuppose that there are some biases in surgical culture. Let's accept that that's probably true. And so Maybe the top 10% of all surgically inclined male medical students will get to a surgical residency. And then to be very simplistic about it, let's say all of them become practicing surgeons. And then let's say that there are some biases in surgical culture such that maybe 5% of surgically inclined female medical students end up in surgical residencies and practicing surgeons. So the top 5% in each gender will be technically equivalent, but for the female surgeons, that's where the whole cohort ends. And for the male surgeons, there's another equally sized cohort that isn't as good. So the best male surgeon and the best female surgeon are probably equivalent, but the average male surgeon is not as good as the average female surgeon because of that wider cohort. And when we think historically it's not like it's a two to one phenomenon, male medical students to female medical students entering surgical residencies, it's in some cases up to 10 to 1. And so I think you truly have to be a particularly exceptional woman to end up being a surgeon. And in some specialties, like subspecialty surgeons that are very heavily male dominant, you think of aspects of neurosurgeons surgery, cardiac surgery. In our urology field, it's my corner of the globe with urologic oncology, it's a very, very male dominated field. And so any woman who makes it through to the end of that career trajectory is clearly abnormally good.
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B
Yeah, but it's like if it was the other, the first thing you talked about, where they're more, they spend more time, they optimize better, blah, blah, you can move those widgets and be like, hey dudes, start doing these things. But if you're like, dude, these are just like the super rangers. There's going to be super Rangers and by any profession there's the top 1% because of bias, because it's so hard for the females to get there, they've already gone through the filter of like being the 1%.
- [13:37]
A
Yeah. And my feeling is it's both. And we're working on it, but we're seeing differences in how people practice. And certainly there's data going back over 30 years saying that men and women in medicine, not specifically in surgery, and that's why we're trying to fill the gap right now, practice medicine differently. So the idea that they practice differently is there. The question is, is that because we've selected more exceptional people or is it a learnable skill set? Probably it's a bit of both. But just because we're selecting exceptional people doesn't mean we can't learn from them. Right. Like I want to go around, you know, as a trainee, I was going around to try and find the best possible surgeons and hang out with them to pick up things that may or may not have been intuitive to them. But even if they weren't intuitive to me, hopefully I could learn them and apply them to my own practice. And so there's no reason why we can't apply that same mentality to things outside technical skill acquisition.
- [14:29]
B
Yeah, I mean, another piece of data, I don't know if this was yours or something you quoted when I heard you on the podcast is women have less deaths, we have less complications, we have less readmissions. But female surgeons are punished more for, for their complications. And what I think it specifically is, is if, if the community finds out that you have a complication, you're way less likely to be referred more cases than a man who's had a complication. Do you want to talk about what, what you know about that?
- [14:55]
A
Yeah. So this is work that's done by an economist named Heather Sarsons. It's really, really interesting work. So exactly as you described, she looked at, when a surgeon has a complication, what happens to the referral base? And so leading up to that complication, as you'd expect, in general, people have increasing numbers of complications. After a male sur application, his referral pattern essentially continues as you would have anticipated, as if there was no event, it continues to rise. Whereas a female surgeon has a big immediate drop off in the next quarter, and then the referral rate stays suppressed. And Dr. Sarson looked at it out six quarters, that is a year and a half. And it remains suppressed at that point. But arguably the even bigger point than that, and you could say that as a referring physician, maybe it's smart to not refer your patients to a surgeon who just had bad events. Like, that's maybe a bit logical. There's still a gender disparity. And why are you not doing that for the male surgeons? Put that aside. Maybe actually the referring physician should be treating the male surgeons more like the female surgeons as opposed to vice versa. Either way, let's leave that aside. The bigger issue is that Heather Sarson showed that this gets generalized. So if a female surgeon has a bad outcome, all female surgeons in the same specialty in that geographic vicinity, we'll see a decrease in referrals that persists over a year after that event. Whereas no effect is observed for the group of male surgeons within that same specialty if a male surgeon has a complication. So there's what's been termed the Elizabeth Holmes effect, where venture capitalists are hesitant to provide funding to startups headed by women. And in some cases, quoting saying, you remind me of Elizabeth Holmes and I just don't feel comfortable giving, giving you my money. Where there's data that shows that female founders actually provide outsized and unexpectedly large returns on investments, they outperform men in that domain as well in the business world. But there's this generalization of bad outcomes for women that men don't experience. I think it's probably most prominent when there's a very low representation of women. So the less women are in any given field, the more of a problem that generalized effect is going to be.
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B
Yeah, that's shocking. And it leaves me like, what the hell are we supposed to do about this besides, like, flood the system with more female surgeons so that, like, the uniqueness goes away?
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A
Yeah, so that's one aspect, I guess. You know, I take this a bit philosophically. I mean, anyone who's looking at the screen can tell I don't fit your typical DEI description. To be very explicit, I'm a like, cisgendered heterosexual white dude. And I think as odd and sometimes awkward as it is for me to exist in this space, there's an unfortunately necessary role for people who look like me doing this stuff. And again, bouncing out to the business literature, there's a great study around what is called diversity value and behaviors. And so what these authors showed is that if you are in a leadership position and you are a visible minority or a woman who exhibits these diversity value behaviors, that is supporting other women or visible minorities, you get penalized on performance reports whereby men, and particularly white men, do not get penalized for exhibiting these diversity value and behaviors. And so if we actually think that there's a sort of systemic or societal problem here, unless we're going to allow the people who are currently disadvantaged by the system to be penalized as they try and fix it, fundamentally, white guys need to take this on as our problem and fix the system that currently benefits us the most.
- [18:43]
B
Yeah, I was thinking about that when I was listening to you again on the other podcast because I was like, who better than you to actually bring this research forward? You're more likely to be like, dude, what's his skin in the game with this? Right? Like, he's, he's part of the group that has greater mortality with their patients. Who better than you to champion this? And I feel like if, if a woman was to do it, they'd be marginalized to like, nobody really cares you or, or believes that this data, or you're biased. You're trying to just show your, your group is the favored group. So to me, I'm like, please, thank you for doing this work.
- [19:17]
A
Yeah, the trouble is, unfortunately, it gets perceived as self serving. I think when women push this message too hard. And what's interesting that the chair of surgery at my institution is a woman named Carol Swallow, who is an amazing, amazing surgical oncologist. And when I came on faculty and started talking about this stuff, she came up to me, she said, you know, the men 30 years into practice are receptive to you talking about this in a way that they have never been. When I've tried to bring it up over the last couple of decades. And this is someone who outranks me. She's full professor. I had just started. You know, she's the chair. She's got an enormous international reputation. And yet even within my institution, my older male colleagues were more amenable to hearing it from the guy, like, a year into practice than they were hearing it from the chair of the department.
- [20:09]
B
We see this, you know, just online and social media, the female physicians who are trying to educate the population about whatever it might be, urology, hormones, health, blah, blah, blah. And when the New York Times has done this, multiple different arenas will write up on it and they'll say, Dr. Peter Attia, Dr. Mark Hyman, and multiple female influencers. The men get to stay doctor when they educate, and the female doctors are influencers. And it's so insulting. And to all of us, like, it's so obvious what's happening.
- [20:43]
A
Yeah. And the trouble is, like, that's at a societal level, but even within our profession, we're no better. Right. There's the great papers on introductions at conferences or ground rounds. And if a female moderator is introducing speakers, they'll almost always use the appropriate titles. If a male moderator is introducing a male speaker, they usually use the titles. And if a male moderator is introducing a female speaker, they very rarely use the titles. It's an intersectional concordance effect between the genders that predicts what's going to get used. And it's when the men are in charge, the female titles don't get used.
- [21:22]
B
Absolutely. Let's talk about this part of your research. So it's not only the gender of the surgeon, it's the gender of the patient. And that's what blew me away, is like the people who did the worst, correct me on any of this if I'm wrong, but the people who did the worst were the female patients operated on by male surgeons. Were you shocked by that?
- [21:44]
A
I wish I was, but I actually wasn't. So I want to give you context for this study. And we've subsequently replicated it a number of times. But let's go back more than a decade, and I am a third year medical student. The first rotation of my third year of medical school is general surgery. And I'm out in a community hospital where there are no residents. So it's me and the staff. And one of the HPV surgeons is an amazing woman named Allison Ross. And on my first day of third year of medical school, I am first assist as she does a hepatic lobectomy, takes off like half of somebody's liver. And the next day we go to round on this patient together in the hospital. Recall that she got consent from this guy, she did his operation, he's now doing shockingly well, and he addresses every question he has about what should happen for the rest of his life to me as she stands beside me at his bed. I, like, barely could find an elevator in that hospital at that time, let alone know anything about hepatic cancers. Right. And I never had a way to sort of action that experience for a long time. But it doesn't shock me to know that there's that interplay. And so. So what you're alluding to, what we did is we looked at something called, or the way we termed it was sex concordance. So if a patient and their physician are of the same sex, that is male patient, male physician, female patient, female physician, then in general, they did better if they were discordant. But the trouble is that assumes that male patient, female surgeon is the same as female patient. Male surgeons, as you've already said, it's not. So what we saw, interestingly, is that for a male patient, they had somewhat better outcomes if they had a female surgeon. But when you went to female patients, the effect was magnified, like two or three fold larger. For example, for a male patient, there's about a 12% reduction in your risk of mortality by having a female surgeon. If you're a female patient, it's 32% difference. So when we think about so many things in life and in society, if you are in the dominant group, you're more protected. So the effect of any other factor going on around you is less important when you are in the dominant group. So as a man, the effect of physician sex has less influence on me. As a white person, the effect of physician race probably has less influence on you. And so it doesn't shock me to see this. And again, we've recapitulated this in the internal medicine space. Got a meta analysis of this? I think the best example is actually not our data, but comes out of Florida emergency rooms. Because you can argue that in the surgical context, particularly elective surgery, patients may select their surgeons, surgeons may select their patients. But when you're going into the emergency room and you're having a heart attack, you don't really get to choose who your doctor is. You get whoever is on at the time. And so what they showed is, number one, if you walked in with a heart attack to a Florida emergency room and the ER doctor responding was female, you were more likely to survive full stop. And number two, if you were a man walking in, you had a much smaller difference between having a male physician and a female physician than if you're a woman walking in. Or put a different way, if you walk into the emergency room and there is an ER doctor who is a woman. On. The difference between being a male patient and a female patient is quite small. We all know that women having heart attacks, it tends to be a bit atypical, and their outcomes are a little bit worse than men. But if there's a female physician, that difference is actually very small. If there's a male physician, the delta for a patient being female versus being male is much, much larger. So you can think of it that the underlying biases against the female patient from our healthcare system are magnified when it's a male treating physician as opposed to a female treating physician. It's not to say that there aren't some systemic biases that still persist that aren't alleviated entirely by having a female physician, but certainly they're minimized.
- [25:58]
B
Yeah, it takes me to the next step of like, okay, fine, we've got some exceptional people who are doing exceptional things. That's fine, though, because we all get paid based upon, oh, wait, the average Female physician makes $98,000 less a year than the average male physician. Not only are these people having better outcomes, less mortality, saving the system money, because they have decreased readmissions, decreased surgical complications, better MI outcomes for your hospital, thank you very much. All the rankings, they get paid less. Like, at some point, Chris, like, how are you sleeping at night? It's not even like we pay them all the same. And some are exceptional. It's like we pay the best people almost $100,000 a year less than the other people.
- [26:47]
A
And here's the catch 22. The trouble is that probably a lot of the behaviors that female physicians exhibit that lead to better outcomes actually harm them professionally. So, for example, we know, and this has been known for over 30 years now, that female physicians spend more time with their patients. There's a fair bit of data. Ours is one. There's a great JAMA surgery study that focused specifically on cholecystectomy that also looks at, for the average operation, women are a tiny bit slower, like five minutes per case slower. Probably not enough to meaningfully change hospital throughput numbers, but enough to maybe affect patient outcomes. And so, unfortunately, in medicine, even in the context of places where people are salaried, it's really a volume game. And most physicians generate more money by seeing more patients. And it's not a quality based metric that leads to remuneration, it's a volume based metric. And so moving faster, even if it's a bit sloppier, arguably is going to help your income. So that's number one. Number two. So there's long standing issues that I've heard come up around the inability or lack of skill of women to negotiate for themselves.
- [28:07]
B
I want you to continue. But it's like women get told to negotiate and then when they negotiate, they get punished for it, Correct?
- [28:13]
A
Yeah, that's the exact bias. The trouble is that when women exhibit behaviors that are often favored in men, they get penalized because they're not playing by standard gender roles. So when you step outside your gender role, you often make people uncomfortable and often they will pull back from you or penalize you from doing that. So even in negotiation, if you go to a salary model and you say you know what, volume doesn't matter at all, which to be fair, almost doesn't exist in any healthcare system I'm aware of, there's still an underlying issue. And then take it a step further. Let's go to people like the deans of medicine. So these are the people who want to talk about the exceptional people in medicine. These are the exceptional people in medicine. You have to jump through a million hoops to become a dean of medicine. You take deans of medicine and you correct for their years of experience and you correct for their research publication track record and you correct for their grant capture. And female deans of medicine or female chairs of medicine get paid less than their male counterparts. So there is no output metric or quality metric you can come up with that obliterates the pay divide.
- [29:26]
B
Right. Even if you're at the very top of the Mount Everest of medicine, there's still. You haven't out climbed the gender punishment.
- [29:35]
A
Correct.
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B
One cool thing that came out of electronic medical records is that women physicians get 20 to 40% more messages in their EMR from nurses, from patients, from people than men do. And that's all unpaid work.
- [29:52]
A
Yeah, I mean the things you see, and I hear it only secondhand questions being directed to female physicians because, oh, I can't bother that other male physician, he's so busy. But you're so approachable. I mean emr, digital equivalent of the same thing that we've been seeing in clinic all the time, which is that dating back 30 years, there's data women spend more time, and in part of spending more time, they don't get just more Biomedical information, they get more psychosocial information. And, oh, by the way, patients interrupt female physicians more. They're more assertive with their female physician. There's a good and bad to that. Right. It means that the female physician has a harder time practicing, is less efficient in their practice, and that hurts them financially. But they understand a patient's priorities and needs better and probably, as a result, can provide better care. And that's probably why the patient is getting a better outcome. Now, we haven't totally linked each one of those steps on the chain so far. We know we can go from A to D, and there's certain A to B works and C to D works, and we're working on connecting all the links with data, but seems pretty intuitive that that sequence plays out that way.
- [31:04]
B
Yeah, I mean, for me, in urology, I get the complicated patients. And everybody will say that that's a common urology thing of like, this is not a distal pre stented ureteral stone, my friend. Right? Like, this is like, I've been to five other doctors. I have chronic pain. Five Things haven't worked. What do you got for me? And by the way, like, I haven't seen a therapist, and I'm on the brink of divorce, and I'm crying, right? And it's like, what I got, what my management I got told time again, is that I didn't spend enough time with patients. Male partners saw that we had this exact same time blocks in our schedule. They're not getting complaints that they're not spending enough time with patients. So I'm like, you look at burnout and you look at why female physicians are leaving is like. Cause I spend the exact same time, if not more time. And I'm the one that gets the complaints in the office. This is a real good story about Bronx and his dad, Ryan. Real United Airlines customers.
- [32:00]
A
We were returning home, and one of the flight attendants asked Bronx if he wanted to see the flight deck and meet Captain Andrew.
- [32:06]
B
I got to sit in the driver's seat. I grew up in an aviation family, and seeing Bronx kind of reminded me of myself when I was that age. That's Andrew, a real United pilot.
- [32:15]
A
These small interactions can shape a kid's future.
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B
It felt like I was the captain.
- [32:20]
A
Allowing my son to see the flight deck will stick with us forever. That's how good leads the way, for sure. And there's two things there. Number one, it's that last point. Women leave medicine and leave surgery in particular at much higher rates than men do. And part of it Is this. And probably part of it is our inflexibility to all the other demands of life. But to take a step back, society just fundamentally has different expectations for women than men. I jokingly say all the time to my wife that for whatever reason I'm considered a very good, very engaged father by everyone around us. And I would be considered a borderline absentee mother with the same behavior.
- [32:58]
B
Yeah, right.
- [32:59]
A
What we see is that in general, if women actually spend the same amount of time with their patients as men do, as physicians, their patient satisfaction scores, their Press Ganey scores are substantially lower. In order to maintain equivalent scores, they have to put in substantially more time and effort to get to the same place.
- [33:19]
B
Yeah. And for people who don't know what Press Ganey is, it's basically patient satisfaction scores that in many areas are tied to income. In the. For the employed people in my town, it's 7 to 10% of your salary is withheld to be given back to you based upon your Press Ganey scores. And we have data again, if I'm wrong, let me know if I'm wrong. It's both gender biased and it's also racially biased. So humans are punished by society and their pay relies on these things. Like why we haven't banned these for severe discrimination by now is beyond me. Why haven't physicians gotten rid of these or agreed. Why are we signing contracts where our salary is based upon society's belief in how they think we should behave?
- [34:07]
A
Yeah, I mean the trouble is that there's obvious incentives on the institutional end.
- [34:10]
B
To use things like this and to keep the. Keep the cash. Absolutely insane. I mean I think of like, you know, the people, my generation, we've been practicing for about 15 years now. We're effing good at our jobs. We all are. Any gender, you're good at your job. There's no reimbursement for being except an exceptional mid career person. You know, in law, multiple other places like there is an advantage to being really good because you're really seasoned. You've seen a lot of stuff that doesn't exist in medicine. The only way to move the needle is more widgets.
- [34:44]
A
Yeah, and that's where we come back to that volume conversation we had before. Our incentives are aligned to throughput, not to any other quality metric.
- [34:53]
B
Yeah, I mean the other thing with bias I was reading, I think this was a doximity thing that popped up. 75% of women physicians surveyed believe there is a pay disparity. Fewer than 30% of men physicians also believe this is true. And the male physicians will be like, they just work less.
- [35:08]
A
Yeah, I mean, there's so many examples of this. I quote a different paper when I give my talks, but there's, I would term like an allyship gap. Men tend to overestimate how good and fair things are and underappreciate the biases that they've never had to experience. So, you know, I have many, many of my colleagues who tell me that it just ought to be a meritocracy. And it is a meritocracy. And if you're good, you're good. And for example, relatively famously, if you have a panel at a conference that is all men, that must mean that there was no women who were expert enough on that topic to deserve to be on that panel. And then the issue with meritocracy is that it presumes that everyone shows up at the door of medical school with equal opportunities to move forward and build their CV and has the same day to day resources at their disposal and the same external commitments or lack thereof that they have to attend to. And so, you know, I think the idea of meritocracy is a nice theoretical construct that just doesn't apply to living and practicing in society, in our world.
- [36:19]
B
Yeah, I mean, I was thinking about, you know, the research on like infants, dogs, chimpanzees, all of these animals are highly aware of inequality and like, they got the bigger bone. They got two bananas, I got one banana. These mammals who are, we don't think they're, they're not adult humans, right? And they get so pissed about inequality. And then I'm like, you put these women in this system, why wouldn't they be upset? Why wouldn't they leave when they have a chance? And then to be like, well, don't be upset, that's just the way it is. Blah, blah, blah. I'm like, dude, I'm upset about this. I would think anybody who actually sees the data and believes it and realizes not only are they killing people less, they're getting paid less for.
- [37:00]
A
Yeah. And so we haven't talked about it, but it's a good time to bring in the double layer of sort of bias here. Right? So we've talked about how female physicians tend to get compensated less. And to be fair, essentially the Ontario based analysis, which is probably true worldwide, is that even when working exactly hour for hour, the hourly rate that a surgeon can generates as a woman is less than a man. Because we're essentially paid per widget you make. And by taking care of patients in arguably a better way, it takes a little bit longer and so you generate less. But let's take it beyond that. In our healthcare systems, at least as I know them, in Canada and the U.S. taking care of female patients pays less than taking care of male patients. And so another one of my colleagues did a great analysis trying to compare as close as you can get to comparable procedures essentially from gynecology and urology contrasts. And not unanimously, but fairly consistently, the care of female patients generates less income than the care of male patients. And in general, women as physicians are more likely to care for women as patients. And so female physicians doing the same work get paid less than their male colleagues. And then female physicians tend to end up doing more of the work that is more poorly compensated. And so there's actually a double bias there. That means that for the average female physician, it's actually a bit worse than you would expect from just the standard gender based pay gap for the same work.
- [38:42]
B
Yeah, I mean, Jocelyn Fitzgerald is, I think, pioneering that work in America, at least with our relative value units and how, you know, a bleeding uterus gets reimbursed way less than a bleeding prostate to the point that surgery centers are saying it all comes down to dollars. We're losing our OB wards because they don't reimburse. Well, we're losing priority for gynecologic surgery and outpatient surgery centers because they don't pay as well. And so we've got a massive, massive problem.
- [39:12]
A
Yeah, I mean, and then you layered on, not to get too derailed, but other societal issues that are perhaps discouraging OB care. This is going to be a massive, massive issue moving forward.
- [39:24]
B
Yeah, I heard from a friend in Idaho has lost 50% of their gynecologists. Like, it's just an inhospitable place to do your job. So they're leaving the states and that hurts everybody, literally everybody. Because if a woman can't get her care, the whole family's affected. So what would you tell the physicians, all gender physicians, about, Like, I don't think anybody can say at this point that you haven't done enough of these studies. I know you're going to continue to do them, but like, this is looking like what the map is right now. What would you say to physicians? And then once we close that out, I want to. What do we say to the patients?
- [40:00]
A
Yeah, so the, I mean, they're short and long term. Everything's got to have short and long term. So in the short term, this clearly supports the role of women in surgery. This supports institutional change to enable women to practice and stay in surgery, both recruit and retain. I think a bit bigger picture is we're working to understand why patients of female surgeons have better outcomes, to understand the processes of care, because I think, or I hope that some of that will be teachable. So the goal here would be to develop a sort of behavioral intervention that we can teach all medical students, but maybe the men will benefit slightly more than the women from it, so that we can all sort of evolve our practice and look at this not as a male, female thing, but right now as gender being a surrogate for different behaviors. And we need to understand those behaviors so that everyone can practice them optimally. And so, you know, from a physician perspective, I think that's where we're at right now. I think there's a bit more ammunition in the barrels to make arguments to support remuneration discussions, retention and recruitment discussions to really support women in surgery. I know that it has been used in our area to do that to some degree. We've also taken this idea and generalized it a bit to use women as a case study for other marginalized populations with the idea. And just as a quick aside, we tried to do this in race and the current funding issues with the NIH shut down a project about halfway through answering that question more successfully. We're about two and a half years into it and that's essentially dead in the water now. But for example, in our institution, new hiring panels and promotion panels have someone assigned to be edi representation on the panel. And not inherently based on their own identity, but just to look at how does this new hire or promotion affect diversity, equality and inclusion within our institution. And then I think an important component of that is not just to think about it when you're looking at the candidates, but to think about it when you're looking at the assessor. So to make sure that the panels are representative, it's not a series of end of the career professors, but we have representation by race, by gender, by specialty, sometimes by career status. So we've got the full professors, the chairs and the deans, but we've also got mid career people, We've got medical students and residents and fellows involved in these panels. And so taking the idea a little bit more broadly, we're trying to make sure that a diverse group of perspectives come to bear when we're making these kind of decisions. So, you know, I think that's for now what we can do within our profession, hopefully more as we learn more.
- [42:57]
B
What do you say to the patients? What do you say to the general population about this?
- [43:01]
A
Yeah, I mean, there's a couple of ways to view this. Number one, remember that those are relative effect measures and not absolute. So, so let's take that. So that's number one. Number two, it's not realistic that every woman out there who needs surgery is going to get a female surgeon. It's just not going to happen. We don't have the capacity to do that. So what do we really need to do? I think what patients need to do is they need to find a physician, a surgeon that they trust, that they believe that they can communicate well with and they believe they can believes, understands them and their priorities and their perspectives on their health issue. I fundamentally believe that while there are certain technical arguments that can be made, this is not about the cutting and sewing parts of surgery. This is about communication. This is about understanding patients priorities. This is about all those other aspects of surgical care that are outside the or. And so while you may not get a female surgeon, you want to find a surgeon who jives with you and can embody those sort of behaviors and characteristics that we think are leading to better outcomes for the group of female surgeons in general.
- [44:17]
B
Yeah, I think that's beautiful. What would you say to female surgeons in negotiating salaries?
- [44:23]
A
Depends. So I, by personality characteristic I'm a bit nihilistic, so I'll just throw it out there. I mean, I think you go into the discussion knowing that the system's rigged against you. And I think don't be naive to the fact that that is true. And I think if you assume that the system is going to treat you equally to your male partners, you will end up behind the eight ball. And so understanding those biases is good. I think if you can find allies among your male partners, it can really help you. So one of the places I was, some of the female surgeons were hired very similar time to male surgeons. And the male surgeons were very good about communicating with their female colleagues about what was happening in terms of offers and annual raises and bonus structure. And having those allies within your institution can really give you a lot of leverage to push for equal and more appropriate compensation packages, I think. And so not everyone's going to be this way, but I try very intentionally to be very sort of open and explicit. I think the more secretive we are about our compensation and our work situations, the more we can be taken advantage of and the more as a group and as a community we share amongst ourselves, the less likely there is that people are going to get singled out and get taken advantage of.
- [45:51]
B
I love it. This has been a fantastic talk, at least for me. I mean, to me I'm like, dude, I know how many people you see in clinic. I know that you do surgical oncology. You don't have to do any of this work and yet you do. And I want to acknowledge that and I want to thank you for that. You could just be a surgical urologic oncologist, you know?
- [46:13]
A
Yeah. I mean, at this point in time, I feel like I almost know too much. Now I've got like this obligation to keep it going well.
- [46:20]
B
I mean, it's kind of like, you know, if you're anything like me, we're. We start out as these like idealistic medical students and we're here to learn and we're here to, to help people. And we're here to like, you know, want to be friends with the people that we're with. And then you realize the system you're in is so flawed. But who better than the people who've been through the system to actually be the ones to change it? It. You have the most power and oomph and like understanding of it. And so it's beautiful to see.
- [46:52]
A
We just need the will. Because I feel like there's too much in medicine, this philosophy that like, I had it shitty so you have to have it shitty too. Right. You know, like, I suffered, so you suffer. And I think as a group we need to move past that and say like, yeah, some of the things we had to do in training were like really crappy. Let's not make other people have to deal with that.
- [47:14]
B
Yeah, I think that's a beautiful thing. I mean, as mid career as I am and you are like, people are leaving. People are leaving this profession. Me and my physician friends were like, who's gonna take care of us? And so it's like we legitimately see that the rats are leaving the ship because the ship. So it's better to swim in the ocean. Right. And I think mid career people, they see their worth and they're like, this is insane. I don't have to do this anymore. And the only way, I think the only hope is to say, I know you don't want to look at this data, I know you don't want to look at this. This is painful for some people, but we have this and we have to look at it if we want this profession to be as wonderful as it can be, 100%.
- [47:54]
A
And I think we focus heavily on the medical profession. But the reason why people like the Guardian and the New York Times are interested in some of the work that we're doing is that this is a microcosm for society. This isn't a medicine specific problem. I think many, many professions, you know, I've got lots of good friends who are in law or in business or in accounting or whatever. These are sort of behavioral observations that apply beyond the practice of medicine. It's somewhat easier for us to probably quantify them in medicine, and which is why, you know, we can do the studies. You know, the lay press is only interested in this because it's more than just a medicine problem. I think it's a society issue.
- [48:32]
B
Yeah, I love it. What do you hope for? You're raising two girls. What do you hope for them?
- [48:36]
A
Oh, again, back to my nihilism. I hope they don't go into medicine, but.
- [48:43]
B
I hear you. Medical school's nerd camp for sure. It's super fun, but I think the insurance based employed model is frying out a bunch of really hard working, smart, compassionate, loving people. And it's like you can go to nerd camp, but you can also do other things with nerd campus. You don't have to dehumanize yourself in the care of taking care of other people 100%. Yeah. Thank you so much for finding me for letting me find you, sharing all of your research and coming to talk to my big audience of both medical people and the lay population who I know will probably have their mind blown as much as me with this conversation. So thank you.
- [49:23]
A
Oh, my pleasure. Thanks so much for having me on.
- [49:25]
B
Absolutely. Thank you for listening to this week's episode of youf Are Not Broken. If you want to dig deeper with me, sign up for my Adult Sex Education Masterclass where you learn adult things like communication skills, anatomy lessons and desire types, and how to talk to your doctor about sexual health concerns. If you want the Adult Sex Education Masterclass for free, join my monthly membership for more in depth exclusive content, more time with yours truly. A private podcast, coaching and educational empowerment and you can watch my interviews live and get them immediately without advertising. Head over to www.kellycaspersonmd.com for the membership and adult sex ed Masterclass members get the master class for free. This podcast is presented solely for educational, entertainment and informational purposes only. I am a doctor, but not your doctor in this format and all of my platforms and guests, including on this podcast, are not giving individual medical advice or practicing medicine. See in consult with your own care team for your individual needs and concerns. This podcast is not intended as a substitute for the care and advice of a physician, therapist or other qualified professional. This podcast does not constitute the practice of medicine, in case you were curious about that and no doctor patient relationship is formed. But I still love you. Using the information on this podcast or any of my platforms is at your own risk. Until next time, remember, you are not broken.