Investigating gender gap in health care proves to be extremely complicated

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We launched the Power Gap series nearly a year ago on Jan. 21. The first block of stories examined the gender divide in the public sector, with a focus on four key areas: municipalities, provincial ministries, Crown corporations and universities.

We’d collected and analyzed each province’s public sector compensation records – documents known as Sunshine Lists that typically detail the name, compensation and often job title of each high-earning public employee – and then married that data with information on the gender probability of first names provided by Statistics Canada.

Altogether, we were able to create an unprecedented map of where women stand within specific institutions, not just in terms of the gender wage gap, but in the leadership pipeline. (You can read more about the methodology of that phase of the project here.)

We had hoped to include medicine in that initial batch of stories, but we soon learned that investigating the gender gap in health care would be extremely complicated.

Although many provinces release some compensation records for health care workers, physician compensation is not public information almost anywhere. (British Columbia is an exception.)

Doctors in Canada – even ones who work in hospitals – operate like their own small businesses and bill the government directly for the services they provide. Physicians with leadership or administrative roles at hospitals can also be paid by that institution – and those payouts can show up on a Sunshine List – but we learned it was also tricky to rely on those numbers. Sometimes, for example, compensation can be supplemented through other sources, such as foundations, which are not public.

We found it was not uncommon for extremely senior people to be absent from a Sunshine List, despite the fact they were clearly making well above the disclosure threshold (which is usually $100,000). As a result, these public sector disclosure lists could not reliably be used as tools to evaluate gender divides within medical leadership.

Additionally, provinces that release health care compensation data often do not include the job title. This made it impossible to conduct a proper gender analysis for many reasons, including that most nurses are women and half of health care workers on the Sunshine List were nurses.

For these reasons, we had to approach the medical inequities story differently. We decided to focus on Ontario, because its compensation disclosure was the most complete. The Ontario Hospital Association provided us with a list of the 10 highest Health Ministry-funded hospital corporations as of last year.

From there, we reached out to those hospital corporations and asked for organizational charts from 2021, which showed executive leadership as well as medical leadership. (We requested the same information from Alberta Health Services, but AHS was not able to complete the request.)

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Those 10 Ontario institutions (many of which are the result of recent amalgamations and encompass multiple hospitals) are: University Health Network, Hamilton Health Sciences, Trillium Health Partners, London Health Sciences Centre, Unity Health Toronto, The Ottawa Hospital, Sunnybrook Health Sciences Centre, William Osler Health System, The Hospital for Sick Children and Scarborough Health Network.

Through interviews with senior medical officials at different hospitals, we identified key common medical leadership roles: department chief, division head and research leadership positions. (These are people in charge of research institutes that are connected to a hospital but operate as their own entity, such as leaders at The Li Ka Shing Knowledge Institute at St. Michael’s Hospital in Toronto and program heads within the SickKids Research Institute.)

We asked each of the 10 institutions to provide the appropriate names and worked with each hospital to ensure we were doing our best to identify the correct people. Sometimes job titles varied slightly, such as a Department Chief being known as a Department Head. Hospitals are complicated entities and there are many medical leadership positions. We did not include roles such as medical directors, physician leads or service leads. We manually researched the gender of all 671 positions in our dataset. In most cases, the College of Physicians and Surgeons of Ontario identifies the gender of doctors on its website.

It was not uncommon for a physician to serve in multiple roles. For example, a person may be the head of multiple divisions. If this person was listed twice on an organizational chart with different titles, we included them twice. If a person was listed once with a title that included multiple jobs, we included them once. With rare exceptions, we used the information provided from the hospitals.

With Hamilton Health Sciences, it was not possible to assess division heads. HHS appears to have a unique structure that includes a significant layer between Department Chiefs and Division Heads, which is: site leads and deputy chiefs. Although the hospital network does list some division heads, we were not able to establish with HHS which individuals should be included. HHS explicitly asked us to use department chiefs and then site leads and deputy chiefs.

As such, we removed HHS from our overall analysis of the leadership pipeline for all 10 hospital corporations (this is the graphic that shows the gender divide within five job titles in the largest hospital corporations). We left HHS in the individual breakdown of the group of 10, but the layer that would usually look at “division heads” instead shows “site leads and deputy chiefs.”

We also have a graphic that highlights the divide in key leadership roles within the 10 hospital corporations. (HHS is included here.) These jobs include chief medical officer/chief of staff, surgeon in chief, physician in chief and numerous department chief roles. At Unity Health Toronto, department chiefs report to a medical advisory committee, which is chaired by a man. There is also a male executive whose title is “chief medical officer.” We indicated Unity has a male in the role of CMO.

All hospitals are structured differently and not all hospitals have the same departments, although there are many similarities. For this analysis, if one hospital organization had a department chief in charge of emergency medicine and another had a division head in charge of emergency medicine, we only used those at the department chief level.

For the final piece of our analysis, we wanted to look at the race of the women who did reach medical leadership positions. We again individually researched all 671 positions, using online biographies, photos and other reliable resources.

When there were questions, we attempted to contact the physicians directly, although the response rate was almost zero. This was not unexpected given the pandemic and stress on the health care system right now. Some individuals were left undetermined, but their numbers did not impact the overall findings. The division head level contained the most volatility, which is why we could not include a number there.

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