Physician responses to patient expectations can affect their income

Physician responses to patient expectations can affect physician incomes and may help explain lower incomes for many women, racialized, and immigrant physicians, found a new study published in the Canadian Medical Association Journal.

Researchers from McMaster University aimed to understand persistent identity-related income differences among physicians practicing in Canada. They conducted a qualitative study that included interviews with 55 Ontario family physicians.

“Pay disparities related to gender, race, and immigration status persist among Canadian physicians, even within specialties and after adjusting for hours worked,” says Dr. Meredith Vanstone, professor, Department of Family Medicine and Canada Research Chair in Ethical Complexity in Primary Care at McMaster University, Hamilton, Ontario.

“This is seen in family medicine, even though physicians are typically paid via standardized fee schedules. Our study demonstrates that physician responses to the expectations they perceive from patients may contribute to these pay gaps. They told us that patient expectations differ depending on their identities and the identities of the patients.”

“Physicians respond to perceived patient expectations by adjusting their practice and behavior, including the way they interact, the length of an appointment, and the services they provide,” says Dr. Monika Dutt, Ph.D. candidate at McMaster University and family physician. “These are decisions that may ultimately impact income.”

As more women and international medical graduates are practicing medicine in Canada, income inequalities are important to understand and address, particularly as incomes for medical specialties with high proportions of women physicians have been declining relative to incomes in other specialties.

Key points:

• Physicians perceived that their identities and the identities of their patients influenced the expectations patients had of them. For example, patients expected women physicians to spend more time with them and to provide more emotional support. This additional time per visit can reduce the number of patient appointments and, thus, income.
• Study participants reported that patients often preferred physicians of the same gender for certain types of care, including pelvic exams, pregnancy, menopause, erectile dysfunction, and prostate exams. In Ontario, billing fees for intrauterine device (IUD) insertion and cervical cancer screening are low compared with fees for other services.
• Many patients preferred care from physicians from the same cultural or linguistic background. Generally viewed as positive by the physicians in the study, this could pose challenges if patients expected preferential care or services similar to those offered in their home country. As well, racialized physicians described sometimes needing to spend extra time educating patients or engaging in advocacy; this reduces time spent with other patients and affects income.

“Since providing longer, more comprehensive patient interactions limits the number of appointments or services that physicians can provide, women may experience financial disadvantages in compensation models that depend on roster size or patient volume,” the authors write.

To address pay disparities, the authors suggest that compensation models could adjust for extra time required for some types of care. The fee schedule should be examined to make sure that services associated with female anatomy (e.g., pelvic exams, IUD insertion) are not underpaid.

“Ontario family physicians are responsive to the expectations of their patients. This is not necessarily a bad thing, as it is likely to result in satisfied patients whose needs are well met,” Dr. Vanstone emphasizes.

“These findings may be relevant to physician workforce planning and ensuring team-based care that accounts for physician backgrounds and skills to improve patient outcomes,” the authors conclude.