The Pay Gap in Gynecologic Surgery and Its Effects on Training Quality

Introduction

Women in the U.S. are typically paid only 82% of men's wages. ¹ Women physicians and surgeons are paid only 71% of what their male counterparts are paid.^2,3

The wage gap in gynecologic surgery presents what we have described as “double discrimination” ⁴ — lower pay in an area of surgery that boasts of the largest proportion of female surgeons (in 1 study 48% versus a range <1%–19% in other surgical disciplines) ⁵ —and potentially lower-quality care and fewer resources for the field's exclusively female patients. This article expounds on this premise and describes how this pay gap translates to fewer resources and less training for residents in this field. While the terms “woman,” “women,” and “female” are used throughout, these issues affect all persons who seek gynecologic care.

Why is Women's Health Undervalued?

The reasons for disparities in funding for women's health are complex and a full explanation is beyond the scope of this article. Arguably, a full explanation may be nearly impossible to achieve, given how complex systems create disparity. Even so, some contributing factors are discussed herein.

A series of articles dating to 1997 have critiqued the Centers for Medicare and Medicaid Services (CMS) system that sets rates for various procedures.^6,7 The system is complicated and involves setting relative value units (RVUs) as well as other factors that are meant to measure the effort and time for work during various procedures. The authors of these articles found that the rates for some procedures for women are set lower than similar procedures for men, although there is no medically justifiable reason for this disparity.

More-recent studies show some reduction in these disparities; yet, there is still persistent undervaluation of gynecologic surgery. ⁸ These rates do not translate directly to compensation—an intricate entity related to multiple factors. Yet, there is no denying that the starting point for compensation for gynecologic surgeons—especially those whose pay is tied directly to these rates or “RVU based”—falls behind that of urologists. History plays a role as the original set points—many of which are still used today—were determined in the early 1990s by a study from the Harvard School of Public Health that undervalued women's health care. ⁶ Changes to these set points rely, in part, on surveys sent to surgeons by the American Medical Association every 5 years. These surveys define typical time and effort for typical work. Very poor response rates to these surveys and underreporting of time and effort may impact the rates set for gynecologic surgery. ⁹

The CMS system tends to undervalue not only women's health care but also primary care and pediatrics. ¹⁰ Scholars have noted that, as more women have entered these fields, valuation of this work has decreased.^2,11 This has been seen in other professions, most notably teaching. “Women's work” is consistently devalued and deprioritized in U.S. economic and social policy. ¹²

Some might argue that women's health care is poorly reimbursed not because of CMS set points but because women disproportionately have insurance through Medicaid or other lower-tiered insurance policies. Given duties at home, child-rearing without meaningful parental leave, lack of subsidized child care and other barriers, women frequently are unable to access high-tiered insurance that is tied to employment. That this is the case and results in part from other federal policies should be accounted for in a federal system that sets reimbursement benchmarks and must ensure gender equity under the Fourteenth Amendment and provisions of the Affordable Care Act. ⁴

To complete the picture, severe underfunding for research into women's health issues contributes to inequity, not only in access to and development of novel treatments, but also resources in hospital systems that may be influenced by research dollars. ¹³

Some might discount the effects of these factors and argue that the problem is overstated. However, as evidence of the effects of these disparities, many departments of obstetrics and gynecology are “loss leaders” in their hospital systems. Stated another way, hospitals understand that both obstetrics and gynecology are reimbursed poorly and may run “in the red”; yet, these institutions maintain these services because women who trust hospitals where they receive their care bring their whole families to those hospitals. ¹⁴

These issues are decades old. While there have been some improvements over time, women's health started this race for resources at a disadvantage, and equity has not yet been achieved. With less reimbursement comes less funding for administrative support, for nursing support, for research, and for training; and there are fewer seats at the table to advocate for hospital resources including operating room time.

How Does All This Affect Trainees?

The effect of undervaluing women's health care plays out in a variety of ways in practice and in training. Surgical training is significantly shorter than for colleagues in general surgery or urology and women's health care practices are incentivized to focus primarily on obstetrics by billing rates with only 15% of any typical practice devoted to gynecologic surgery. ¹⁵

Historically, when obstetrics was merged with gynecologic surgery, many leaders objected to the truncation of surgical training from 5 years to 18–24 months and the allocation of only 15% of any practice to surgery. ¹⁵ The rationale explicitly stated at the time was that obstetrics/gynecology residents and professionals would be encouraged to know when to call for help as opposed to receiving a full complement of general-surgery training. ¹⁶ Critics at the time contended “that all who open the belly should have the broad surgical skills required for handling all problems encountered there, regardless of organ system involved.” ¹⁵

Recent studies would support the critics. A systematic review and meta-analysis of 14 studies concluded that the link between volume and quality that is well-documented in many other fields of surgery also exists in gynecologic surgery. Low-volume gynecologic surgeons (defined as surgeons in benign gynecology, urogynecology, and gynecologic oncology performing fewer than 12 of a particular procedure per year) have significantly higher rates of bowel and urinary-tract injuries in their patients. ¹⁷

Perhaps in response, graduating obstetrics/gynecology residents are increasingly driven to pursue fellowship training. One of the most competitive fellowships is minimally invasive gynecologic surgery. While individual reasons for these choices vary, studies have shown that graduating obstetrics/gynecology residents may be unprepared to practice surgical gynecology independently.^18–20 It is plausible that some residents hope to address the deficits they find in their training.

Ways Forward

Change is hard and solutions to these issues will be difficult to achieve. More funding for women's health is needed. On a federal level, whatever system exists to set reimbursements must take account of systemic discrimination that might result directly or downstream. Bias is frequently a result of systems—not people—so, while the intentions of those individuals who work tirelessly to achieve unbiased valuations may be good, that is not enough if the effects are objectively inequitable as described here.

As educators, we should feel doubly incensed by the lack of resources in women's health as this directly impacts the quality of training we can provide. Ahead of any federal reforms or legislation, we can pursue other models to approach equity within our own systems. Tracking within our training programs and our practices can lead to improved outcomes for our patients and likely improved surgical acumen for our residents.

The Kaiser Health System provides a model. During a 7-year timeperiod, after clinicians were tracked into either obstetrics or gynecology, surgical outcomes improved for all hysterectomy patients, ²¹ and racial disparities in access to minimally invasive hysterectomy care dissipated. ²² This solution is not possible outside of a large system or large group practice willing to subsidize gynecologic-only practice, because current low reimbursement rates mean that few obstetrician/gynecologists can devote themselves primarily to surgery. ²³ Thus, departments would have to pool resources and pay a rate for value independent of CMS set rates. Many successful benign gynecologic–surgery programs do just this.

A similar model can be used in residency, tracking trainees to higher volumes in areas of interest to increase surgical training. ²⁴ Along with this, we should refocus our milestones to ensure that each resident who hopes to practice gynecologic surgery leaves our training with the ability to perform ureterolysis and repair of the gastrointestinal track and bladder—skills that are not currently explicitly enumerated in case logs but that form the basis of the “broad surgical skills required for handling all problems encountered” in the abdomen. ¹⁵ Many of our residents may be proficient in these skills, and they should be tracked to emphasize their importance.

Yet another solution is fellowship training. A recent study showed that 2 years of fellowship training in gynecologic surgery is potentially equivalent to 19 years in practice. ²⁵ But fellowship is expensive in that it defers earnings while typically incurring debt. Gynecologic-only practice is associated with a significant reduction in earnings, compared with general obstetrics and gynecology, despite resulting in clear benefits for patients as demonstrated by the Kaiser study. Without a system to ensure appropriate pay for gynecologic surgery, we are asking some trainees and gynecologic surgeons to shoulder the financial burden of solutions to systemic problems.

Conclusions

We cannot continue with the status quo. Our patients and our trainees deserve a solution that is developed by our leadership in collaboration with legislators to address historic and systemic wrongs. Many leaders are working diligently on solutions to these issues. Yet, even with these excellent intentions, they are each siloed in efforts that seem geared at absolving these leaders’ particular interests from responsibility. Solutions for systemic discrimination this complex require all of us—health care professionals, trainees and patients—to come together and create change so that we can ensure adequate resources for all women.