Researchers at McMaster University set out to investigate why identity-based income differences persist among physicians in Canada, despite the use of standardised fee schedules in family medicine. To understand this persistent disparity, they conducted a qualitative study based on interviews with fifty-five family physicians in Ontario, focusing on how doctors perceive and respond to patient expectations shaped by gender, race, and immigration background.
Dr Meredith Vanstone, professor in the Department of Family Medicine and Canada Research Chair in Ethical Complexity in Primary Care, explains that income gaps linked to gender, racial identity, and immigrant status persist even within the same specialities and after accounting for hours worked. Their findings suggest that the way physicians adjust their behaviour in response to perceived patient expectations may influence these earnings differences. Many doctors in the study reported that patients’ assumptions and demands varied according to the physician’s identity and the patient’s background, shaping the nature of each clinical interaction.
According to Monika Dutt, a family physician and PhD candidate involved in the research, clinicians frequently alter their communication style, appointment length, and services offered to meet these expectations. While such responsiveness can improve patient satisfaction, it also affects how many patients a doctor can see in a given day, thus influencing income in compensation models tied to volume or roster size.
Several specific patterns emerged from the interviews. Women physicians said they were often expected to spend more time with patients and provide greater emotional support, reducing the number of appointments they could accommodate. Patients also tended to prefer doctors of the same gender for intimate or gender-specific care, such as pelvic examinations, pregnancy-related consultations, menopause care, erectile dysfunction, and prostate concerns. However, fees for procedures like IUD insertion or cervical cancer screening in Ontario remain relatively low, limiting income for those—often women—who provide these services more frequently.
Cultural and linguistic similarity was another influential factor. Many patients preferred physicians who shared their background, which doctors generally viewed positively. Yet racialised physicians noted that these encounters sometimes required extra time to educate patients or provide advocacy, further reducing the number of patients they could see and affecting their earnings.
To mitigate these disparities, the authors argue that compensation models should better account for the additional time required for certain types of care. They also recommend reviewing the fee schedule to ensure that services associated with female anatomy are not undervalued. While Dr Vanstone emphasises that physicians’ responsiveness to patient expectations contributes to high-quality care, the study indicates that recognising and adjusting for these dynamics is essential for creating a more equitable system.
More information: Monika Dutt et al, Family physician pay inequality: a qualitative study exploring how physician responses to perceived patient expectations may explain gender, race, and immigration status pay differences, Canadian Medical Association Journal. DOI: 10.1503/cmaj.250665