Fahima Dossa, general surgery resident at Sunnybrook Hospital, was the lead author on a groundbreaking article published in 2019 that showed female surgeons earn 24 per cent less in hourly wages than male surgeons.Christopher Katsarov/The Globe and Mail
There’s a point in medical school when aspiring physicians have to choose a specialty. When that moment came for Fahima Dossa in 2013, she decided she wanted to be a general surgeon. A barrage of questions from some faculty mentors followed.
“I was asked: Well have you thought about having a family? Are you going to have children?” Dr. Dossa recalls. She noticed the men in her program were not asked these questions.
Her male peers also seemed supported in choosing any area of surgery – cardiac surgery, neurosurgery, urology and others – but Dr. Dossa and the other women were being nudged towards fields that are associated with women, such as obstetrics and gynecology or breast surgery. In the operating room, the little slights continued: Male trainees were encouraged to push themselves, while women seemed to have the instruments taken out of their hands more quickly by the supervising surgeon, limiting their ability to develop and learn.
Collectively, these experiences inspired Dr. Dossa to investigate gender and medicine. She was the lead author on a groundbreaking article published in 2019 that showed female surgeons earn 24 per cent less in hourly wages than male surgeons. It also showed that male surgeons made more per hour than women in almost every surgical specialty – including gynecology.
The study was the first of its kind in Canada, but it was almost never published. Journal after journal rejected it, amid criticism during the peer review process about the authors’ “tone” and the study’s premise.
“One has to assume that [women make less] because they are performing procedures that reimburse less… Men who have chosen to have less in the way of childcare responsibilities may pursue more highly remunerative subspecialties,” one reviewer wrote.
The paper eventually found a home in the U.S. journal JAMA Surgery, as did a recently published follow-up that showed male doctors strongly favour male surgeons for patient referrals. Both articles rank in the top 5 per cent of the journal’s high-impact papers.
For Dr. Dossa, the pushback she and her team encountered in trying to publish this research is emblematic of the wider struggle that female physicians face in trying to address gender inequities in medicine.
“I think people want to believe that these issues no longer exist. ... People want to believe they got to where they are because physicians work in a meritocratic system. But that’s not the case,” said Dr. Dossa, who is now a general surgery resident at the University of Toronto.
“People get promoted based on their accomplishments, but there is a whole demographic group in medicine – that being women – who are not always given the opportunity to acquire the same set of accomplishments.”
Dr. Dossa, shown at Toronto's Sunnybrook Hospital, was one of the many female physicians The Globe and Mail interviewed as part of its Power Gap series to learn about their experiences of inequity at work.Christopher Katsarov/The Globe and Mail
For the past year, The Globe and Mail has been exploring gender inequities in different professions, from corporate Canada and law, to academia and government, as part of the Power Gap series.
In this final instalment, The Globe has examined the divide in medicine, a profession that has perhaps never been so visible to so many because of the COVID-19 pandemic.
Over all, health care is a female-dominated sector and not just because the majority of nurses are women.
Women currently represent 44 per cent of the country’s physicians and more than half of all medical school students. For two decades, the number of male and female first-year medical residents has been more or less equal.
Soon, more doctors in Canada will be women than men. (It’s already near even in family medicine and women make up about a third of surgical specialists.) Yet women remain underrepresented throughout the medical leadership pipeline.
The Globe analyzed medical leadership at the 10 hospital corporations in Ontario with the largest budgets using 2021 organizational charts, and found that just 32 per cent of department chiefs, 29 per cent of division heads and 23 per cent of those with prestigious research positions are women. (These positions include executive director of the Li Ka Shing Knowledge Institute at St. Michael’s Hospital and program heads within the SickKids Research Institute.)
The gender divide within Ontario’s
largest hospital corporations
Men
Women
Presidents
67%
33%
Executives
46%
54%
Department chiefs
68%
32%
Division heads
71%
29%
Research institute
leadership
77%
23%
The Globe analyzed organizational charts from the 10 hospital
corporations in Ontario with the largest budgets. Hamilton
Health Sciences could not be included in the above overall job
title analysis for methodological reasons, but it was possible
to assess HHS individually.
The gender divide within Ontario’s
largest hospital corporations
Men
Women
Presidents
67%
33%
Executives
46%
54%
Department chiefs
68%
32%
Division heads
71%
29%
Research institute
leadership
77%
23%
The Globe analyzed organizational charts from the 10 hospital corporations
in Ontario with the largest budgets. Hamilton Health Sciences could not be
included in the above overall job title analysis for methodological reasons,
but it was possible to assess HHS individually.
The gender divide within Ontario’s largest hospital corporations
Men
Women
Presidents
67%
33%
Executives
46%
54%
Department chiefs
68%
32%
Division heads
71%
29%
Research institute
leadership
77%
23%
The Globe analyzed organizational charts from the 10 hospital corporations in Ontario with the largest budgets.
Hamilton Health Sciences could not be included in the above overall job title analysis for methodological reasons,
but it was possible to assess HHS individually.
Proportion of men and women in
hospital leadership
Men
Women
London
Health
Sciences
Centre
Scarborough
Health
Network
Sunnybrook
Health
Sciences
Centre
0
0
50%
50%
0
50%
President
100%
100%
100%
Executives
72%
37%
67%
28%
63%
33%
Dept. chiefs
72%
71%
80%
28%
29%
20%
Div. heads
75%
68%
63%
25%
32%
37%
The
Hospital
for Sick
Children
The
Ottawa
Hospital
Trillium
Health
Partners
0
50%
0
50%
0
50%
President
100%
100%
100%
Executives
36%
64%
20%
42%
80%
58%
Dept. chiefs
80%
20%
92%
75%
8%
25%
Div. heads
74%
26%
82%
68%
32%
18%
Unity
Health
Toronto
University
Health
Network
William
Osler
Health
System
0
0
50%
50%
0
50%
President
100%
100%
100%
Executives
56%
43%
22%
44%
57%
78%
Dept. chiefs
29%
67%
80%
71%
33%
20%
Div. heads
69%
64%
85%
31%
36%
15%
Hamilton
Health
Sciences
* For HHS, we could
not analyze division
heads. This row shows
the gender divide with
deputy chiefs and site
leads, a unique layer
within HHS’ medical
structure.
0
50%
100%
President
50%
50%
Executives
73%
27%
Dept. chiefs
71%
*Div. heads
29%
Proportion of men and women in
hospital leadership
Men
Women
London
Health
Sciences
Centre
Scarborough
Health
Network
Sunnybrook
Health
Sciences
Centre
The
Hospital
for Sick
Children
0
0
0
50%
50%
50%
0
50%
100%
100%
President
100%
100%
72%
37%
67%
36%
28%
63%
33%
64%
Executives
72%
71%
80%
80%
28%
29%
20%
20%
Dept. chiefs
Div. heads
75%
68%
63%
74%
25%
32%
37%
26%
The
Ottawa
Hospital
Trillium
Health
Partners
Unity
Health
Toronto
University
Health
Network
0
0
0
50%
50%
50%
0
50%
100%
President
100%
100%
100%
56%
20%
42%
43%
44%
80%
58%
57%
Executives
29%
92%
75%
67%
71%
8%
25%
33%
Dept. chiefs
Div. heads
82%
68%
69%
64%
32%
31%
36%
18%
William
Osler
Health
System
Hamilton
Health
Sciences
* For HHS, we could
not analyze division
heads. This row shows
the gender divide with
deputy chiefs and site
leads, a unique layer
within HHS’ medical
structure.
0
50%
0
50%
President
100%
100%
22%
50%
78%
50%
Executives
80%
73%
20%
27%
Dept. chiefs
*
Div. heads
85%
71%
15%
29%
Proportion of men and women in hospital leadership
Men
Women
The Hospital
for Sick
Children
London
Health Sciences
Centre
Scarborough
Health
Network
Sunnybrook
Health Sciences
Centre
The
Ottawa
Hospital
0
0
0
0
0
50%
50%
50%
50%
50%
President
100%
100%
100%
100%
100%
Executives
72%
28%
37%
63%
67%
33%
36%
64%
20%
80%
Dept. chiefs
72%
28%
71%
29%
80%
20%
80%
20%
92%
8%
Division heads
75%
25%
68%
32%
63%
74%
26%
82%
18%
37%
Trillium
Health
Partners
University
Health
Network
William Osler
Health
System
Hamilton
Health
Sciences
Unity
Health
Toronto
0
0
0
0
0
50%
50%
50%
50%
50%
President
100%
100%
100%
100%
100%
Executives
44%
43%
57%
56%
22%
78%
50%
50%
42%
58%
Dept. chiefs
75%
29%
71%
67%
33%
80%
20%
73%
27%
25%
*
Division heads
31%
69%
64%
36%
85%
15%
71%
29%
68%
32%
* For HHS, we could not
analyze division heads.
This row shows the gender
divide with deputy chiefs
and site leads, a unique layer
within HHS’ medical structure.
Compared with medical leadership, women’s numbers increased dramatically at the more visible executive level. These are often individuals who are not physicians, but who are chosen for their experience running large organizations.
At this highest echelon, 54 per cent of executives and 33 per cent of the presidents were women.
One constant was that the majority of senior leadership is white. Among Ontario’s 10 largest hospital corporations, only 16 per cent of female executives appear to be racialized women. (Of the men, 22 per cent appear to be racialized.) At the department chief level, about 30 per cent of the people in this role appear to be racialized. (The numbers are similar for men and women). And there appear to be only two non-white hospital presidents.
Brian Hodges, chief medical officer at the University Health Network, which includes Toronto General, Toronto Western and Princess Margaret hospitals, said his institution has made a major push on diversifying medical leadership in the past few years. At UHN, these roles come with fixed term limits, so there is an opportunity to correct historic imbalances with fresh talent.
Last year, UHN appointed its first-ever female physician in chief, and it has reached gender parity among division heads in the medical department, Dr. Hodges said. Progress has been more difficult on the surgical side, he added, which is a problem that starts in medical school. Only one of UHN’s eight division heads in surgery is a woman, although just days ago, the network hired a second woman. She will become their first female head of cardiac surgery.
“We are making headway, but in 2021, headway is probably underwhelming,” he said.
The gender divide within
key medical leadership roles
Each square represents a hospital
corporation with this position.
A slash represents a hospital corporation
with multiple chiefs in that role
who are of different genders.
Men
Women
Chief
medical
officer/
Chief of staff
Physician-in-
chief/Chief
of medicine
Surgeon-in-
chief/Chief
of surgery
Chief of
anesthesia
Chief of
emergency
medicine
Chief of
family
medicine
Chief of
laboratory
medicine
Chief of
medical/
diagnostic
imaging
Chief of
mental
health/
psychiatry
Chief of
obstetrics-
gynecology
Chief of
pediatrics
Source: each hospital corporation provided organizational
charts for 2021.
The gender divide within
key medical leadership roles
Each square represents a hospital
corporation with this position.
A slash represents a hospital corporation
with multiple chiefs in that role
who are of different genders.
Men
Women
Chief medical
officer/Chief
of staff
Physician-in-chief/
Chief of medicine
Surgeon-in-chief/
Chief of surgery
Chief of
anesthesia
Chief of
emergency
medicine
Chief of
family
medicine
Chief of
laboratory
medicine
Chief of medical/
diagnostic imaging
Chief of
mental health/
psychiatry
Chief of
obstetrics-
gynecology
Chief of
pediatrics
Source: each hospital corporation provided organizational
charts for 2021.
The gender divide within key medical leadership roles
Each square represents a hospital corporation with this position.
A slash represents a hospital corporation with multiple chiefs
in that role who are of different genders.
Men
Women
Chief medical
officer/Chief
of staff
Chief of
laboratory
medicine
Physician-in-chief/
Chief of medicine
Chief of medical/
diagnostic imaging
Chief of
mental health/
psychiatry
Surgeon-in-chief/
Chief of surgery
Chief of
obstetrics-
gynecology
Chief of
anesthesia
Chief of
emergency
medicine
Chief of
pediatrics
Chief of
family
medicine
Source: each hospital corporation provided organizational charts for 2021.
Because of the complicated way that physicians are paid, it was not possible to assess the gender pay gap for doctors over all. For the most part, physician compensation is not public. (British Columbia is one exception.) Doctors essentially operate as their own small business, billing the government directly for the clinical work they do. Each “service” – whether it’s a family doctor dealing with a sore throat or a surgeon removing a tumour – has a code with a fixed fee.
This system is what leads many to dismiss the inequities, said Michelle Cohen, a family doctor who also researches the gender pay gap in medicine.
“The first knee-jerk response – particularly from men who don’t really want to deal with this – is we have a fee-for-service billing code, so those billing codes are gender neutral, so you just get paid for the work you do,” Dr. Cohen said.
What these critiques miss, Dr. Cohen said, is that the system sets up women to earn less. Women are steered towards less lucrative specialties. Even within specialties, women earn less than men. An analysis by the Ontario Medical Association found pay gaps in lower-paying specialties that are dominated by women, as well as in higher-paying specialties, which are made up primarily of men. Over all, the OMA identified an unexplained 13.5-per-cent gender pay gap in daily earnings.
Women also tend to see patients longer and therefore see fewer patients in a day, Dr. Cohen said. One reason is that societal bias places women in the role of caregiver. Doctors who expect their patients to require more counselling are more likely to refer to a woman, she said. Women are also judged more harshly if they violate gender norms by not appearing nurturing enough.
One surgeon who works at a large Canadian research hospital told The Globe she has had formal complaints lodged against her by nursing and administrative staff for offences that include: having a “condescending” tone, raising her voice and fostering a “non-collaborative” environment. The doctor acknowledges she lacks a soft touch and is not always a patient person, but neither are many of her male colleagues and for them, it’s a non-issue.
Dr. Cohen said another common rationalization for the gender wage gap is that women work less. This is true, but the differences in hours and pay do not line up. In British Columbia, a 2017 study of primary care physicians showed that women made 36 per cent less than their male counterparts, but worked just three hours less a week.
“It’s also pretty obvious why women are working less,” Dr. Cohen said. Women who work outside the home are still doing the majority of domestic labour. This holds even when both spouses are physicians, studies show.
What does it mean when men and women at public institutions don't get access to the same pay or prestige? Investigative reporter Robyn Doolittle runs through some of the key takeaways from The Globe's investigation.
The Globe and Mail
To better understand the issues that female doctors are encountering, The Globe interviewed two dozen female physicians from across the country, including family doctors, surgeons, specialists and hospital executives. (The majority spoke on the condition of anonymity, as they feared career ramifications for publicly addressing these issues.)
Many of their complaints were similar to those from other industries: A female hospital CEO described being told she sounded too arrogant; an emergency room physician said she was probed during job interviews about whether she planned on having children; a surgeon watched a less qualified, more junior male colleague be promoted above her.
All of the physicians diagnosed the same core problem for women in medicine: Within society, deeply entrenched gender biases remain in which people expect men to be doctors and women to be nurses.
“The male doctors – and male students even – were treated as if they were gods. And the women were treated as if we … were not legitimate,” said one physician, discussing what it’s like to work in a hospital.
The physicians believed this dynamic contributed to qualified women being overlooked for senior positions. Almost all of them had stories about meeting a patient only to be asked when the doctor will be coming.
Many of the themes that came up in these physician interviews played front and centre in the high-profile Human Rights Tribunal of Ontario case between Irene Cybulsky and Hamilton Health Science.
In 2009, Dr. Cybulsky became HHS’s first female head of cardiac surgery. In fact, she was believed to be the only one in Canada. All seven of the surgeons in her charge were men and in 2014, following “grumblings” about her leadership, HHS launched an internal review. Some of the men complained that she had “unfriendly body language,” she was not “soft” enough, and she was “like a mother telling her children what to do.”
In 2016, Dr. Cybulsky was not reappointed. She alleged her ouster was a result of gender bias and discrimination and earlier this year, the tribunal agreed with her, but the events torpedoed her medical career. Dr. Cybulsky enrolled in Queen’s University’s law school and graduated last year.
“That story ends with her leaving the profession, which is something that happens to so many women,” Nancy Baxter said.
Dr. Baxter was a general surgeon, professor and scientist in Toronto before moving to Australia in February, 2020, to become head of the Melbourne School of Population and Global Health. She is an unusually prolific and lauded researcher in the area of cancer screening and cancer survivorship, but in recent years she has made it a side project to cast a light on gender inequities in medicine. (She was the senior author of Dr. Dossa’s studies on the surgeon wage gap and referral bias.)
“I thought, if I don’t try to do something, nothing is ever going to change. I’m a Gen Xer, and I think most of us just thought … in 20 years, it’s going to be a different world. It’s not. And it’s been quite disappointing,” she said.
Dr. Nancy Baxter, shown at her Toronto office, says she's disappointed at how little things have changed for women in medicine over the years.Jennifer Roberts/The Globe and Mail
Dr. Baxter said things are still so backward that even writing about gender and medicine can be a career risk, because some in the profession just don’t want to hear it.
She shared an example from a 2020 paper she co-authored that showed female surgeons who also had faculty appointments were less likely than men to be promoted to full professor. During the peer review process, one reviewer with the Canadian Journal of Surgery commented: “[It’s] lamentable that of all things we need to understand better and discover in the realm of surgery, this frivolous topic has usurped any energy and resources.”
Although these types of comments are infuriating, Dr. Baxter says it pushes women to do more.
When Dr. Dossa and Dr. Baxter’s paper on the gender pay gap among surgeons was published, some critics brushed off the findings by arguing that female surgeons just weren’t doing as many surgeries, ignoring the anecdotal evidence that women aren’t given as many opportunities. So Dr. Baxter, Dr. Dossa and their team got to work analyzing referral patterns. They proved their point in black and white data that male doctors disproportionately send patients to male surgeons.
“This one was really important for me ... it’s the gaslighting that happens. The guys act like you’re the worst surgeon and that’s why you aren’t getting the referrals,” Dr. Baxter said. “On an individual level you can say it’s something about this woman. It’s her fault. But when you look at all of Ontario and it’s everywhere, that’s entrenched gender bias.”
Power Gap: More from the series
In data
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Video
Sarah Kaplan, Director of the Institute for Gender and the Economy at University of Toronto Rotman School of Management, discusses the gender power cap in leadership and one way to start to close it.
The Globe and Mail
More reading
How can we bridge the gender power gap? Six ways employers, governments and men can do better
Twenty years of the Power Gap: How 15 Ontario universities compare
Locked out of the ivory tower: How universities keep women from rising to the top