This study showed that female urologists and general surgeons treated significantly more female patients. Although female urologists had comparable patient numbers, revenues, and surgical volumes as their male counterparts, female general surgeons provided significantly lesser patient care in outpatient and inpatient settings and generated lesser monthly revenues. Although female general surgeons performed more oncological surgeries per month than their male colleagues, there was no significant difference in oncological surgical volume after exclusion of breast cancer surgeries. We also observed that female gynecologists had comparable outpatient services and outpatient revenue but significantly lesser monthly inpatient services and surgical volume. To the best of our knowledge, this is the first nationwide study in Taiwan to examine the gender gap in the field of surgery. Exceptionally, gender gaps in service volume, surgical volume, and revenue were not evident in urology. Additionally, female gynecologists did not have advantages over their male counterparts in inpatient service volume, surgical volume, and revenue. These trends vary from those prevalent in western countries 12. These gender gaps are likely multifactorial and warrant further exploration.
Despite the narrowing sex ratio of medical students in the past decades, gender disparity is still present in certain medical specialties. Female physicians, as a growing population in the physical workforce, have greater opportunity to devote themselves to the field of pediatrics, family medicine, internal medicine, and obstetrics-gynecology 13–15. Surgery is pervasively perceived as a male-dominant field. In the present study, there were less than 10% female urologists and general surgeons. There are several obstacles, including gender discrimination, paucity of female role models, and work-life imbalance, that hinder female physicians from choosing surgery as a career option 10,16−18. Gender-based discrimination from patients, trainers, or colleagues is the most bothersome issue for female surgeons. For example, they are frequently labeled as nursing staff or refused by male patients owing to embarrassment 18,19. Barnes et al. also reported that female surgical trainees in male-dominant fields have more microaggression experiences than those in female-dominant fields 10. Moreover, female trainees have been reported to be granted less autonomy by faculty than male trainees of the same level in the operation room 7.
Gender disparity in wages in surgical subspecialties has been well described in several studies, and can be considered as an obstacle for female surgeons to develop their career 5,6,8,20,21. We found that female general surgeons and gynecologists generated significantly lesser revenue than male general surgeons. Although we were unable to obtain exact salaries of female and male surgeons directly from the LHID 2000, the revenue from diagnosing and treating patients could reflect the differences in the incomes between female and male surgeons. The cause of gender-based wage gap is multifactorial. For example, the marital status and practice patterns of female and male physicians contribute to the wage gap. Okoshi et al. reported that the annual income of male physicians increased with an increase in the number of siblings, while that of female physicians decreased 8. In the present study, female gynecologists tended to provide outpatient services more frequently, while male gynecologists offered inpatient services more frequently, which might result in disparities in their wages.
Both female general surgeons and gynecologists performed fewer surgeries than male general surgeons and gynecologists. This indicates that gender stereotypes may have been a negative influence for female surgeons in certain aspects. Sharoky et al. proved that female and male surgeons with similar backgrounds could achieve equivalent postoperative outcomes when treating similar patients 22. An online survey by Ashton-James et al. showed that male surgeons received higher ratings for their knowledge, skill, and capability from patients, while female surgeons scored higher in goodwill, empathy, and beneficence 23. Patients chose male rather than female surgeons when they needed surgeries, especially major oncological surgeries. Furthermore, female surgeons voluntarily changed their practice patterns, which affected their patient numbers and surgical volume directly. In the present study, we found that despite a comparable amount of outpatient services, female gynecologists had significantly lesser inpatient services and surgery volume compared to male gynecologists. As observed by Antonoff and Brown, to be a wife and a mother, or even a single woman, female surgeons must modify their practice patterns to achieve work-life balance 24.
However, gender stereotypes may contradictorily exert a positive impact on female surgeons to some extent, especially when history-taking, physical examinations, and surgical procedures involve the female sex organs 25. No gender preference was observed in other surgical subspecialties not involving sex organs, such as orthopedics or plastic surgery 26,27. In the present study, female and male urologists had comparable performances regarding patient service volume, surgical volume, and revenue. This finding is compatible with those of other studies concerning urological patients 28,29. Similarly, we found that female general surgeons performed more radical breast cancer surgeries in Taiwan. A Greek study showed that about half of the women who had been previously treated by female surgeons preferred female breast surgeons 12. Patients’ feelings of being understood, less embarrassed, and less anxious, as well as previous positive experiences with same-sex surgeons are major advantages for female urologists and breast cancer surgeons in clinical practice.
Interestingly, Nam et al. reported that female urologists in the United States were favored to deliver female-specific care. However, the compensation derived from the care of oncological patients was significantly lower for female urologists compared to male urologists 6. Female urologists in Taiwan performed a similar volume of transvaginal and oncological surgeries compared to their male counterparts. Oberlin et al. reported that among every subspecialty, female urologists operated on a greater proportion of female patients than their male colleagues 30. This might account for the comparable performance between male and female urologists in Taiwan. Despite the challenges for females to become surgeons, becoming a urologist may be a good choice for women in the Asian culture. The lifestyle, diversity of procedures, and combination of the practice of medicine and surgery might be the most positive influential factors for female physicians to pursue urology 31–33.
There are several limitations to the present study. First, the LHID 2000 did not include information on the subspecialties of individual surgeons. Therefore, we included surgeons with 6 to 13 years of experience; this range ensured that the surgeons were well-trained and not subspecialty-focused. Second, data from surgeons who did not join the National Health Insurance despite being few in number was missed in the LHID 2000. Third, the revenue contribution from diagnosing and treating patients may have been underestimated because data regarding self-pay services could not be obtained from the LHID 2000. Fourth, we did not use questionnaires to gather information on the marital status of surgeons, as well as their subjective perceptions, motivation factors, and struggles. These may have influenced their practice.