Gender, Racial and Immigration Pay Gaps in Canadian Family Medicine: Qualitative findings from a mixed-methods analysis

<h3>Context:</h3> Pay gaps in medicine have been documented along gender, racial, and immigration identities. These pay gaps are well documented outside of Canada, but little empirical work has been done to understand pay gaps in Canada, in family medicine, or using an intersectional lens. <h3>Objective:</h3> Understand how the identity features of Ontario family physicians (e.g. gender, race, immigration, nation of medical training, parenting status, age) impact their income. <h3>Study Design and Analysis:</h3> Reflexive thematic analysis was used for the qualitative portion of a mixed-method explanatory sequential study. Previous quantitative work guided recruitment and data collection strategies. <h3>Dataset:</h3> Interview data from 36 family physicians working in Ontario, purposively recruited for diversity in the self-reported time scheduled for a typical intermediate assessment (A007) and identity features. <h3>Outcome Measures:</h3> Outcomes were qualitative descriptions of decisions, circumstances, and factors which impacted income opportunities. <h3>Results:</h3> 36 family physicians described ways in which their income was impacted by identity, with factors grouped in three categories: patient population, philosophy of practice, and circumstances of work. For example, women physicians were likely to note that patients expected more time for counselling. They were also more likely to provide in-office gynecological procedures (e.g. cervical sampling, IUD insertion) described as poorly re-imbursed for the time and resources required. Physicians who provided care in a language other than English or French or are racialized described patient expectations of them that did not concord with the time-limited system in Ontario, and sometimes described heightened patient need. Different philosophies of practice were described, with physicians who emphasized the income-generating functions of their work making choices to charge and collect block fees or fees for unremunerated services (e.g. sick notes) while others emphasized patient care and accessibility, sometimes sacrificing income to provide better care (e.g. offering virtual visits on request). Physicians aligned with the latter philosophy were predominantly women, often racialized, and sometimes immigrants to Canada. <h3>Conclusions:</h3> Attention to intersectional experience highlights how income is influenced by social location. It provides explanatory evidence for quantitative findings of various pay gaps among Canadian physicians.