By ANONYMOUS, MD (3)
There are a few truths that seem to be glaringly ever more important in contemporary society. One is that the feelings of the elite trump facts. Another is that the capture of venerated institutions is so complete that they are frequently used to present feelings as fact.
No better example of this relates to the always contentious physician gender pay gap problem that is examined in a recent study published in the esteemed New England Journal of Medicine. The study seeks to examine the different practice patterns of men and women physicians to understand why men in medicine seem to always make more than women in medicine. Most questions have multiple potential answers, but the answer to this particular question is already known by the IYI class of physicians and researchers that torture data to create the type of glossy PR that would make tobacco executives jealous. The researchers use a mediocre study to spin a tale of woe for women physicians despite the fact the results of the study should leave anyone with more than an ounce of objectivity to quite different conclusions. I must also pause to say that the fact that this weak study gets published in the NEJM with an accompanying editorial confirms the journal’s place on the vanguard of the feelings>facts social justice movement.
The job description for those writing these studies that specialize in confabulation is simple. First, find some dataset of men and women physicians, and then manipulate the findings to spin some tale of societal systemic discrimination that oppresses women. Ganguly et. al. are professionals, and don’t disappoint.
Understand what these motivated researchers are up against .. they have to arrive at the conclusion that women are being unfairly treated despite the fact that those who pay for medical care don’t have a different pay scale for men and women.
The dataset comprises one year’s worth of visits documented in one electronic medical record system and the initial results are damning. It turns out that the reason for the difference in pay is actually the same reason the NBA players make more than the WNBA: Women physicians make less money than Male physicians because they generate less revenue than their male counterparts.
The difference is actually fairly stunning. During the year in question Female PCPs generated 12.4% less visit revenue than male PCPS in the same practice. This translated into women bringing in, on average, $44,718 less than their male colleagues (with a confidence interval that ranged from $28,912 to $60,525). Why this happens is also fairly simple and non-conspiratorial — women happen to be doing significantly less work than men as measured by the number of patients seen. Not only do Female PCPs work fewer days per year, they also see 10.8% fewer visits per year.
Salvaging these results to spin the appropriate narrative required researchers to examine the amount of time they could ascertain was being spent by doctors per patient visit. This was done using EMR time stamps which rested on clinicians clicking on “Go To Exam” to start the visit, and at the end of the visit, clicking a button to advance the visit to the checkout stage. It may sound foolproof, but it isn’t on a number of levels. Some physicians did not record timestamps, or timestamps were recorded in a manner not compatible with reality. The authors could have chosen to exclude those with no timestamps, but chose instead to impute this value ( a common approach to missing data in data sets). No reference is made in the paper to how many data points had to be imputed. Nonetheless, these machinations result in the discovery that women may be spending 2.4 minutes more per visit than men (CI 2.1 – 2.6). This then leads to the conclusion that women physicians work fewer days, schedule substantially fewer visits, but are attempting to compensate for this by spending more time with patients per visit. The authors then have the cojones to posit that women may be using this time to provide better care. They provide no evidence of this because they simply made up that assertion. Remember folks, this is in the New England Journal of Medicine !
The supposed point of this research was to understand why male physicians make more than women physicians. It would seem that question is resoundingly answered. 16,422,457 visits seen by 5284 male physicians, with an average visit time of 15.3 minutes translates to 47,551 minutes of direct patient care time per male physician per year. 7,969,353 visits seen by 3018 women physicians with an average visit time of 17.6 minutes translates to 46,474 minutes per female physician per year. I’m pretty sure that means that male physicians are spending more time in direct patient care per year than women physicians. While its possible the extra 2 minutes spent per patient by women physicians results in massive important gains to the individual patient, this stretches the bounds of plausibility and again, nothing to support that assertion is provided in this paper.
Everyone who has actually practiced medicine also knows that each minute of direct patient care translates to many many minutes of indirect patient care. Seeing more patients means that many more insurance authorizations to do , medications to order, charts to sign, consultants to talk to… the list goes on and on. Given this, there is little doubt male physicians are spending considerably more minutes of their lives taking care of patients per year than women are.
Its very hard to know what physicians are actually making because most of it is based on survey data, but based on this study the average pay difference between male and female primary care physicians in the United States should be at least $50,00, if not more. The authors use the results to call for a different mode of payment that focuses less on volume of patients, and perhaps more on time. This would be interesting, though it is again laughable that the 2 minute difference found is being used to propose massive policy changes despite the fact most would agree a significant effect on patients is implausible, and there is no supporting data to even suggest that women are using those extra 2 minutes in a productive manner. .
Objective, unbiased public health researchers would be anxious to test the hypothesis that men may be more efficient at seeing patients without sacrificing quality, but that’s a non-starter because the only hypothesis that is allowed to be confirmed at this time in the 21st century is that men are worse than women. The whole argument is profoundly silly of course, because it is entirely possible men and women are perfectly happy practicing in whatever manner they choose at work because life as structured in 2020 results in men and women having different priorities. Men, on average, may be seen as the primary breadwinner in their family unity, and be expected to work more to fulfill that role. Its entirely possible that women, on average, are not being forced to take a primary role as caregivers for children, but instead choose to spend more minutes with their children rather than with patients at work. This isn’t to argue to preserve these traditional male and female roles, it just describes the nature of the world as it is, not how those that occupy the ivory towers want the world to be.
It’s worth noting that the rules as they currently exist mean women may choose to make more than the average woman, and the average man.
Would the researchers have been happier to find that women physicians make equal or more money than their male counterparts despite seeing far fewer patients per day and per year? Would that be fair to male physicians that would then be making less money per unit of care delivered in the current payment scheme ? Given who’s in charge and given the fawning nature of the coverage of middling papers like this that find themselves published in the New England Journal of Medicine it seems more likely than not the rules in some future point will be written to specifically favor one gender over the other.
The easiest path to equity would be for a single payer entity to emerge that would pay a flat annual salary to both men and women physicians regardless of work done. Only an idiot would think the annual salary chosen by this entity would be more than the current ‘floor’ that women reside on.
Amidst much uncertainty, one thing is certain, the current path promises to leave all genders poorer.