A new study by McMaster University researchers reveals a chain of influence in primary care: How family physicians perceive expectations from their patients — often shaped by doctor and patient’s race, gender or cultural identity — can affect how they deliver care, which in turn impacts their earnings.
The dynamic may help explain why women, racialized individuals and immigrant doctors often earn less than their peers.
The research, published in the Canadian Medical Association Journal on Nov. 17, sought to understand what’s behind identity-related income gaps among Canadian physicians.
After conducting a qualitative study that included interviews with 55 Ontario family physicians, researchers developed a four-stage theory:
- Doctors perceive that patients have expectations about how care should be delivered. Doctors report that these expectations are shaped by both the doctor’s and the patient’s gender, race, or markers of immigration status.
- Specific expectations vary depending on both the physician’s and the patient’s identities. For example, patients may expect women doctors to be more emotionally supportive, or assume racialized doctors from the same culture understand their own cultural practices or can deliver care in another language.
- Physicians often adjust their behaviour to meet these expectations, spending more time with patients, offering emotional support, offering certain procedures or services, or engaging in cultural advocacy.
- These adjustments can reduce income, especially in payment models that prioritize patient volume.
“Pay disparities related to gender, race and immigrant status persist among Canadian physicians, even within specialties and after adjusting for hours worked,” says senior author Meredith Vanstone, professor with the Department of Family Medicine at McMaster and Canada Research Chair in Ethical Complexity in Primary Care.
“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.”
“The Ontario family physicians we spoke to told us that patient expectations differ depending on the doctor’s identities and the identities of the patient.”
As more women and international medical graduates are practising 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.
“Physicians respond to perceived patient expectations by adjusting their practice and behaviour, including the way they interact, the length of an appointment, and the services they provide,” says lead author Monika Dutt, a PhD candidate in the Health Policy PhD program at McMaster and family physician.
“These are decisions which may ultimately impact income.”
The paper included contributions from Katrina Shen, Gwen Feeny, Danielle O’Toole, Boris Kralj, Arthur Sweetman and Andrea Carruthers.
To address pay disparities, researchers 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 — pelvic exams and IUD insertion, for example — are not underpaid.
“Ontario family physicians are responsive to the expectations of their patients. This is not a bad thing, as it is likely to result in satisfied patients whose needs are well met,” Vanstone says.
The study was supported by a grant from the Canadian Institute of Health Research and a Vanier Canada Doctoral Award.