Grant: Prize: IHSPR Rising Star Award

Background: Sex-based income disparities are well documented in medicine and most pronounced in surgery. In salary-based systems, disparities are commonly attributed to differences in hours worked. One proposed solution to close the earnings gap in medicine is a fee-for-service system, where physicians are paid for each service provided (such as the system in Ontario). In theory, such a system should be free from sex bias; however, it is unclear whether fee-for-service systems are truly less prone to sex-based earnings gaps in the real world. The objective of this study was to determine whether male and female surgeons have similar earnings for each hour spent operating in a fee-for-service system Methods: This cross-sectional, population-based study evaluated claims submitted by surgeons in Ontario for surgical procedures performed between January 1, 2014, and December 31, 2016. We compared earnings per hour spent operating between male and female surgeons within and across surgical specialties. We also explored factors potentially associated with earnings disparities, including differences in procedure duration and type between male and female surgeons Results: We identified over 1.5 million surgical procedures claimed by 3,275 surgeons. Hourly earnings for female surgeons were 24% lower than for male surgeons. In some specialties, earnings differences were more than $70/hour. There were no differences in time taken by male and female surgeons to perform common procedures; however, female surgeons more commonly performed procedures with the lowest hourly earnings Conclusion: This study demonstrates that even when equal hours are worked, female surgeons earn less than male surgeons and have fewer opportunities to perform the most lucrative surgical procedures; increasing hours worked will not close the gender-pay gap.These findings call for a comprehensive analysis of drivers of sex-based earning disparities and highlight the need for systems-level solutions.