Episode 23 -Structural Sex Discrimination in Gynecology and the Law
Show notes
Transcript
Show notes
In this episode, our host, Dr. Melcher, is joined by Dr. Christopher Robertson, a professor at Boston University, and Dr. Louise King, an assistant professor of medicine at Harvard Medical School. Together they explore groundbreaking research recently published by these two co-authors in the Emory Law Journal. The article, titled “Structural Sex Discrimination: Why Gynecology Patients Suffer Avoidable Injuries and What the Law Can Do About It”, delves into the systemic challenges and legal implications faced by gynecology patients.They discuss their motivations for researching this topic, their main findings, and the shocking realities faced by gynecology patients. The conversation highlights actionable steps listeners can take to contribute to solving these issues.
Why Listen?
Tune in to learn more about structural discrimination in gynecology and the legal strategies that can lead to better healthcare outcomes for all.
Key Highlights:
• The inspiration behind the article and why gynecology patients often face avoidable injuries.
• Insights into the systemic discrimination within gynecology and how legal frameworks can evolve to offer better protection and care.
• Personal experiences shared by Dr. Louise King on how these issues impact her work and the broader medical community.
Additional Information:
• Read the Full Article: Published in 2024 in the Emory Law Journal here: https://papers.ssrn.com/sol3/papers.cfm?abstract_id=4800783, or here: https://scholarship.law.bu.edu/faculty_scholarship/3797/
Keywords: Structural Sex Discrimination, Gynecology Patients, Avoidable Injuries, Legal Frameworks, Human Rights Advocacy, Access to Justice, Health Policy, Emory Law Journal, Medical Discrimination.
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Transcript
Interview with Christopher Robertson and Louise King
[00:00:00] Intro
[00:00:00] Dr Miranda Melcher: Hello and welcome to Just Access. In this podcast series, we talk to some fascinating people, including legal experts, academics, and human rights advocates from all walks of life. Through these conversations, we explore ideas about the future of human rights and improving access to justice for all. Our goal is to educate the wider public and raise awareness about human rights.
[00:00:23] After all, our motto is, everyone can be a human rights defender. My name is Dr. Miranda Melcher and I’m a Senior Legal Fellow at Just Access and the host of this podcast. In today’s conversation, we’re going to be discussing the research behind a very important article that has recently come out in 2024 in the Emory Law Journal, titled “Structural Sex Discrimination, Why Gynecology Patients Suffer Avoidable Injuries and What the Law Can Do About It.”
[00:00:51] The article was written by three different authors, and I have the honor of conversing with two of them today. Dr. Christopher Robertson, who [00:01:00] is a professor at Boston University and Dr. Louise King, who is assistant professor of medicine at Harvard Medical School. They will be talking us through how they got into this kind of research, the main findings, the shocking findings of this paper, and what any of us can do to try and help.
[00:01:19] Interview
[00:01:19] So to start us off, can I ask you each to introduce yourselves a little bit and tell us kind of how you got interested in researching and investigating these sorts of topics. Louise, would you mind going first?
[00:01:41] Dr Louise King: Of course. I am a surgeon so these topics affect me quite deeply, not only because it affects how I can gather resources for my patients, but also, frankly, the take home pay that I bring home to my family, and I know that both of those are less [00:02:00] than they would be if I’d chosen a different discipline. I think the most
[00:02:04] frightening and upsetting part of that is how it then translates into the care that I can provide patients and the care that I see them receiving nationwide as they end up at my tertiary referral hospital.
[00:02:16] Dr Miranda Melcher: Christopher?
[00:02:18] Dr Christopher Robins: Hi, I’m Christopher Robertson. I’m a law professor and professor at the School of Public Health at Boston University and I’m really drawn to these sorts of issues, trained first as a philosopher and biomedical ethicist, and second, as a lawyer and social scientist, I’m really interested in how healthcare decisions are structured. We see them on a day to day basis, sort of the tip of the iceberg, the patient talking to her doctor and choosing a course of care.
[00:02:43] What’s really exciting about this topic is we go way upstream to see how those choices are constructed economically, organizationally, that really define even what range of options are possible or presented to the patient. And so that really excites me.
[00:02:59] Dr Miranda Melcher: [00:03:00] So it’s that systemic level then, Christopher, that kind of got you into this sort of research?
[00:03:04] Dr Christopher Robins: That’s right.
[00:03:05] Dr Miranda Melcher: Louise, how did you decide to look at this larger picture?
[00:03:09] Dr Louise King: I started looking at it, again, when I realized that the resources that I had available to me were very different than the resources in other surgical disciplines and that the training that I received, although I did an OBGYN residency and then I did a two year advanced surgical fellowship, but the training even in that larger training path is still less than I would have received if I trained in general surgery or urology or name your surgical discipline.
[00:03:38] And so the fact that my discipline is segregated to only women and that we have the least amount of training and the least amount of surgery, excuse me, resources in general of all surgical disciplines just felt wrong to me, let alone appropriate. So I dug [00:04:00] deeply into why that would be. I guess as a medical student, we don’t really learn about billing and, and how money’s come into the system in the United States or even elsewhere.
[00:04:10] And, and it just took me down quite a rabbit hole.
[00:04:14] Dr Miranda Melcher: So, this gives us a good background for the article that kind of most of our discussion today is drawn from. Before we get into the details of it though, could you perhaps give us the big picture takeaway listeners should understand, even if they’re not legal experts?
[00:04:27] I mean, hopefully our conversation will allow them to get into those details, but to start off kind of the big picture thing to be aware of from this?
[00:04:37] Dr Christopher Robertson: The big picture point is that the health care that patients receive, people with uteri, especially women is at a whole different level of quality and care than we expect and receive in virtually every other domain of health care and surgery.
[00:04:53] And the reason that is so, goes way back to some policy choices made and how we pay for [00:05:00] health care in America and that has structured the entire profession of medicine accordingly and the resources that are allocated and ultimately, this leads to worse outcomes for for, for people with uteri, in terms of lifelong disabilities, incontinence, pain, and suffering that could largely be avoided if we structured this area of our healthcare system more rationally.
[00:05:25] Dr Miranda Melcher: So let’s get in then to those decisions. What, what actually is that structure that leads to those outcomes? There’s a lovely acronym in the article.
[00:05:32] I’d love for you to unpack a little bit the A-M-A-R-U-C. What is it? Is it even something we can know about or is it all a secret? And why do we need to know about this organization?
[00:05:45] Dr Louise King: The AMA should be known to at least American audiences because its the American Medical Association. There are other AMAs. There is an American Motorcycle Association, which my father is the president, just throwing that out there.
[00:05:59] Dr Christopher Robertson: A lot more [00:06:00] fun.
[00:06:00] Dr Louise King: Yeah, very different. He loves to talk about how we both work. At the AMA at times but the American Medical Association is a wonderful organization that’s been around for a very, very long time, and they have a relative value work committee or the RUC that looks at these RVUs, another acronym, the relative value units that get assigned to each piece of work that we do.
[00:06:28] Those, in turn, track back to a study done in the early 90s by Harvard School of Public Health to try to assign values to typical actions and procedures and visits and things that we do in our offices, trying to, I mean, a good purpose, trying to create more equality and how people charge prior to that physicians charge what was typical in the area that they were working in, or could make any charges that they wished.
[00:06:56] And now, those RVUs define [00:07:00] specifically, and through statute, what you would pay if you were on Medicare or Medicaid, our national programs, but also are used by all of our myriad private insurers to set costs. Tracking back a little bit further, the reason that the AMA the doctors themselves are in charge of this, is they’ve been asked by CMS, Center for Medicaid Services or Medicare Services, to set these prices.
[00:07:27] And CMS is in turn given that duty by the government of the United States through statute that was enacted. And so it’s a passing down of the baton to the physicians themselves to set the prices. There’s a good reason for us to set our own expectations of this, of what our work is and, and what it should be paid because we are the experts in what that work entails, but there’s very serious problems in that as well that have been pointed out by many, many researchers before us.
[00:07:58] And they’re obvious, [00:08:00] right? There can be bias that’s introduced. Our system of creating those estimates is based on surveys that are sent out, but are almost never answered and are typically answered in a way that is advantageous to the different groups. So tons of problems and the biggest underserved groups within the RVU estimations of services are internal medicine or preventative health care, pediatrics, and obstetrics and gynecology.
[00:08:26] Dr Christopher Robertson: Let me just add that we looked at the membership of the AMA REC. And only 12 percent of the members are women. So just looking at the representational diversity, it’s a huge skit skewed towards men and the subspecialty of surgeons that specialize in women’s surgical care.
[00:08:45] The gynecologists have zero seats on this committee of their own, where there are a range of other surgical specialties and relatively small groups of physicians like ear, nose, throat doctors or ophthalmologists who have their own seat on this committee, including urologists [00:09:00] as well.
[00:09:00] So you see that’s that’s one of the aspects in which the the inequity is structural. It’s built into how we define this committee and that then waterfalls down to the sort of problems we’ll talk about later.
[00:09:11] Dr Miranda Melcher: So in fact, it is that water falling down I’d like to turn to, kind of how does this committee make their recommendations and how does that then lead to safety concerns in the operating room with surgery?
[00:09:23] Dr Louise King: Yeah, it’s a complicated system, but essentially there are surveys that are sent out and every group of surgeons, specific to surgery, remember the RVUs apply to every type of medical care, but we’re talking primarily about surgery here, but the surveys are sent out and the surgeons fill them out about the amount of time that they put into a typical surgery.
[00:09:47] And then along with that, the committee estimates the complexity of the care that’s provided during that surgery and the equipment that’s required and perhaps even some of the insurance and overhead costs and all of that goes [00:10:00] into a number that is then assigned to that particular code that we have to use when we perform the surgery.
[00:10:06] So we perform the surgery, assign the code and send the billing out. And there are a variety of other factors in terms of negotiations that happen, for example, between large hospital groups and private insurers to set prices around those codes. But that’s the starting point for every bit of pay that we receive.
[00:10:25] So then to connect that to care, unfortunately, within our system and I think everywhere, money is is exactly how we achieve resources and time and and effort. So, because of the way that gynecology has traditionally been reimbursed poorly, we have less access to operating rooms, less access to ancillary supports like physician assistants or nursing or whatever it might be.
[00:10:55] So if I want to book a surgery, my hospital is less [00:11:00] inclined to book my surgery for gynecology as they are inclined to book a urology service case, right? Or an orthopedic case. You can see it in the operating rooms that I can access. Sometimes I get assigned to the orthopedic operating room. It’s three times the size of mine, full of gleaming new equipment and stainless steel.
[00:11:22] And mine is so small that sometimes we can’t even maneuver around to get our cases done. Another way that quality is affected in gynecologic surgery. is the training that I mentioned earlier is shortened and focused primarily on obstetrics. And that’s because although obstetrics itself is also underfunded in the United States, it is funded to a greater degree than gynecologic surgery for good reason.
[00:11:48] The American College of OB GYN has one seat on that committee, and in that power structure, they focus very much on ensuring that we have adequate funding for maternal health, because we have a lot [00:12:00] of problems in maternal health. So I don’t want them to change their focus. They occasionally focus on increasing billing for gynecology, but not often, and that’s primarily, I think, because of their focus on maternal health, but also because OBGYNs generally only do surgery 10 to 15 percent of their practice at most, most of the people who are in general practice.
[00:12:22] They’re mostly on the labor floors or in clinic. There are no other disciplines where surgeons are operating so infrequently and there is, although not, Well, you can argue the point, but we clearly see in many, many, many studies that volume in a particular surgical discipline will translate to quality.
[00:12:44] And if you have very low volume in surgery, you’re more likely to have injuries and complications. It’s not always true, I recognize that, but it’s mostly true. And so that’s how the relationship happens.
[00:12:57] Dr Miranda Melcher: Thank you for [00:13:00] explaining how those different pieces get linked. What, if anything, can be done about this?
[00:13:05] I mean, obviously, Luis, as you’ve demonstrated, there’s a lot of aspects that kind of, on the ground, as one individual surgeon, it’s very hard to operate within this sort of system, both literally and figuratively. But this is, quite clearly, as you’ve demonstrated, a systemic injustice. Is this about people suing?
[00:13:21] Are there other things that can be done? Who can even be sued? I mean, what options are there?
[00:13:27] Dr Christopher Robertson: Maybe I’ll start at the bottom. And so in the paper, we describe a 12 step causal story that leads down this waterfall all the way to patients getting really bad outcomes from, from some very sensitive surgeries.
[00:13:41] And so the often the first thing you might do in America, if you have a bad outcome from a surgery, It’s considered suing your surgeon. I mean, it’s not, that actually happens quite rarely, we don’t have the epidemic of litigation in the U. S. that some people like to talk about, but but that would be your first option and for the most part the [00:14:00] courthouse doors are closed to that sort of approach. And that’s because the problem is structural. No particular physician, who is doing what is normally done and it leads to a bad outcome, those bad outcomes are essentially normalized. They become sort of typical.
[00:14:14] And, and you can’t, for a variety of reasons, you can’t really sue for what’s happening typically against a particular doctor. Second thought would be a surgeon could maybe try suing their employer saying, I’m paid less than, than those urologists across the hall. And, and they tend to be men as, as surgeons and they tend to be treating male patients.
[00:14:35] There’s possibly a litigation approach there. But again, that’s really attacking the employers who are also sort of downstream from the real problem and we haven’t actually ever seen this particular case litigated in the past, but the sort of analogous cases will sometimes allow the employer to say, we’re not discriminating, sort of, they are upstream.
[00:14:58] So the next potential [00:15:00] solution is to sue the insurance companies and the private insurance companies in the U. S., I think, actually make a decent target here. Because although they use the federal government’s discriminatory pay rates, there’s no legal rule that they have to. So ironically, the private payers could be held to the federal non discrimination law in a way the federal government itself can’t, for a reason I’ll discuss in a moment.
[00:15:23] So there is a federal law that was created as part of the Affordable Care Act, the law that was passed during the Obama administration that prohibits discrimination in all federal healthcare programs. And again, although there hasn’t been a lot of litigation under that provision, except for, for cases involving trans rights, I actually think the insurance companies are somewhat exposed here and we hope they hear this message and at least they change their practices because it’s quite doable.
[00:15:50] The last solution is to try to sue the federal government itself, but ironically, Congress has given them immunity CMS, the Center for Medicare and Medicaid Services, [00:16:00] are immune from lawsuits, even if they discriminate in their setting of these rates. But in the, in our paper, we discuss some, some rather technical exceptions or ways to try to work around that immunity. Ultimately, you could try suing under the, the U. S. Constitution does have an equal protection clause that that arguably would provide some recourse here, but it gets fairly complicated and, and we’re not sure that, that this judiciary would be as receptive as we would like. So as we’ll discuss, litigation may well be useful to raise the profile of this issue and get some attention.
[00:16:35] And it, it could even work, but, but we’d need to find some lawyers willing to dedicate a few years and, and a lot of money to fighting this battle. So, I’ll leave it at that for the litigation strategies on, on say four different levels.
[00:16:48] Dr Miranda Melcher: That’s very helpful to outline and just wild to realize some of these things, like been granted immunity, even if there’s like quite clear discrimination.
[00:16:57] I mean, that alone is definitely a piece of [00:17:00] information worth making sure more people are aware of. And I think in some sense it speaks to the fact that, although what we’ve been talking about, I mean Louise you carefully defined it, is a specific issue. We’re talking mainly about surgery, we’re talking specifically about OBGYNs, we’re talking mainly about harms coming to people with uteri.
[00:17:18] But this isn’t happening in a context of kind of everything else being perfect either, right? This is very much linked to wider systemic injustices around OBGYN practice more generally, around gender inequities in medicine and healthcare, right? And honestly, we can probably talk about this being related to inequities that go even beyond medicine and healthcare into broader society, right?
[00:17:41] Am I making sense with those links? Is that something you think we can see?
[00:17:44] Dr Louise King: Well, I certainly believe that. I think you’ve articulated it beautifully. Certainly within the United States right now, there’s an attack on persons with uteri in terms of issues around abortion and accessing care for abortion in [00:18:00] terms of the way that we Underpay women who work in almost every profession.
[00:18:04] And when women join professions, the pay for those professions goes down. Think of teaching, for example over a long period of time. So, I agree with you. I think that it’s linked to a bigger problem. If you track all of this back to the Harvard School of Public Health analysis that created the RVU system,
[00:18:23] they barely looked at obstetrics and gynecology. It was like an afterthought. They did all this work around many, many other disciplines, but obstetrics wasn’t something they really considered to any great degree. So, we started almost with one hand tied behind our back in this RVU chase, and that is so, such a perfect image of how many women in this country and around the world struggle to just try to keep up.
[00:18:50] Dr Christopher Robertson: Let me add that we also see this in funding for research on women’s care. There’s a huge disparity in how much is spent on diseases that affect men versus affect [00:19:00] women. And we also see this in some interesting intersections with, with other identities. In race, for example, Dr. King has taught me that the certain gynecological issues are particularly problematic for people of color.
[00:19:12] And so, like a lot of the sort of injustices we see in our society, black and brown people sort of bear them disproportionately badly. So gynecological care is especially problematic. And the second really interesting intersection is around rural people in America. If you’re here in Boston, there’s a decent chance that if you need gynecological care, you can end up in the care of someone like Dr. King, but if you’re in, say, rural South Dakota, this problem , is really exacerbated because the nearest fellowship trained gynecologist might be a thousand miles away. And so this structure of the healthcare setting also really disadvantages rural people in America who are further from academic medical centers.
[00:19:53] And so it’s interesting to see these intersections hit different populations, which also I think hopefully create some [00:20:00] opportunities for broadening our discussion to different populations to fixing the problem.
[00:20:03] Dr Miranda Melcher: So let’s in fact do that. Let’s talk about other ways of potentially fixing the problem.
[00:20:08] Christopher, you outlined a number of litigation strategies. Are there broader reforms as well that could help with this?
[00:20:15] Dr Christopher Robertson: I think so. And let me just start with saying that AMA RUC, the committee, has been created as this sort of strange regulatory black hole in the USA. We have a great law in America called FOIA, the Freedom of Information Act, we have another law that applies to all federal advisory committees to create some transparency and some accountability, but the AMA RUC moves hundreds of billions of dollars in our society, and it’s not accountable to either of those laws. So it operates in secret and it won’t even release for analysis or independent peer review some of its own studies.
[00:20:54] So a very basic reform is, if the AMA RUC is going to continue to have a [00:21:00] role at all, it needs to be treated like a real advisory committee, an adjunct of the federal government. Frankly, I think it should have some decent balance of gender. I also think that it should have some patient representatives.
[00:21:13] Although Dr. King’s exactly right, I’m not a physician, so maybe I can have a slightly different point of view. Yes, physicians are the experts here, but this is actually the patient’s bodies that are at issue. And I don’t like the idea of outsourcing. These are actually ontological decisions about what healthcare even we conceive as our society.
[00:21:32] If we give it a billing code, it exists. Like, what are those procedures we need to prioritize and how much they’re worth are fundamentally democratic decisions and I’m not comfortable with completely outsourcing them to the industry or the profession of doctors to choose for themselves, especially since they’ve had 30 years to do it and haven’t, don’t have the best track record on this particular issue.
[00:21:53] So that’s, that’s just a couple minutes on what to do about the AMA RUC. There’s some downstream issues as well.
[00:21:59] Dr Louise King: [00:22:00] But I’d agree with that 100% although I do think we’re the experts in telling, you know, getting to the nitty gritty of a particular procedure. We absolutely need more transparency, more reporting out from this committee and you know, public members of the committee, experts from other sources within the life sciences, as not just doctors, but sociologists and social workers and people who understand the other ramifications of the care we provide.
[00:22:29] There’s so much we could do to make this committee better. I am a huge minority when I say all of that. I get a lot of flack for having that opinion, to be very honest with you. And that’s also part of the problem. It shouldn’t be courageous for me to say that we need a transparent committee when it comes to how we fund healthcare, given what the downstream effects of that are.
[00:22:54] It shouldn’t be courageous for me to say we should have other experts and, and members of the public on that [00:23:00] committee and that, and that we should be open and, and completely honest about how we’re arriving at such important data points.
[00:23:08] Dr Miranda Melcher: Would you mind telling us a bit more about why that is courageous?
[00:23:12] Cause from the outside, that does seem a bit strange. It’s like, well, as, as was discussed, you know, these are decisions that affect a lot of people. Of course we would, wouldn’t we want all the different kinds of expertise? And yet apparently that’s not how the system’s been designed. And that is not, you know, that is kind of a radical suggestion.
[00:23:28] Why is it radical? Why don’t we have these sorts of links between disciplines, between kinds of expertise?
[00:23:34] Dr Louise King: Well, the links between I don’t think anybody would argue with me if if we just added a couple of sociologists or social workers or, you know, whatever it might be into the mix, but they would argue if I wanted to open the doors and have anybody come to the meetings to have the meetings minutes.
[00:23:54] Published I’ve served on the rock as a representative non voting. I’ve also served on [00:24:00] committees at a cog to that, that gather the information that’s been submitted to the rock. But even in those roles, I still wasn’t able to do my own analysis of any of the data that they were debating. They would keep a lot of things very confidential and I, I believe the reason is because
[00:24:19] potentially putting on my glasses and thinking, oh, maybe it’s rose colored glasses. Maybe it’s because they don’t, it’s just complicated stuff and they don’t want people to become confused. That was actually the reason given, but I would argue it’s because they don’t want to rock the boat. There are clearly areas of medicine that are underfunded, but there are equally clearly areas of medicine, and I will point fingers, orthopedics, I’m talking about you, that are deeply overfunded.
[00:24:47] And so if we rock that boat, there are going to be some big changes that would happen. And that’s what people don’t want to see. I’m not sure why everybody in that boat [00:25:00] is. Of agreement that they don’t want to rock it when many of them specifically pediatrics, I mentioned them earlier, but pediatrics, preventative care, and OBGYN are deeply underfunded.
[00:25:09] I don’t know why they don’t band together and, and make a run of it, but they don’t. And so when I speak like this, I get a lot of flack. I get Email flack, I get colleagues giving me flack. It, it’s definitely affected, I think my career and I’m okay with that. But yeah, no, people don’t like it at all, at all.
[00:25:32] Dr Christopher Robertson: Let me just add it for the listeners. I hope you’ll pull the paper and look at figure two. We show a dramatic relationship between the take home pay of physicians in America by specialty versus the percentage of women who are in that specialty as, as physicians or surgeons. And the downward relationship is dramatic.
[00:25:55] It’s one of the strongest statistical relationships I’ve seen as a social scientist, [00:26:00] meaning that the more women are in a subspecialty, the less that subspecialty earns. And we’re not just talking about a few percent or a few thousand dollars. We’re talking about some specialties in America that are almost all men earning five to six times as much as the specialties that have more women when we’re talking about gynecology or pediatrics, preventative medicine.
[00:26:21] And so it is, I mean, putting patients interests aside, even if this didn’t result in botched hysterectomies or sometimes even deaths on a surgical table, if even if it didn’t lead to that, the relationship here I’m talking about is obscene. I’ve never seen anything like this. In other areas, we talk about women earning say 88 cents on the dollar compared to men.
[00:26:44] But here we’re talking about orthopedic surgeons earning five times what gynecological surgical specialties earn. It’s, it’s just mind blowing.
[00:26:54] Dr Miranda Melcher: Yeah, I have to say, I’m not a statistician, that’s not my expertise in the social sciences. I did not [00:27:00] need any help understanding that figure. It was so incredibly dramatic that you don’t necessarily need to understand every detail of the numbers to really get that point. And so I’m wondering because of that, because it is such a dramatic finding to be clear to kind of anyone who’s not an expert, what has the reception been like of this research? Have you, you know, Louise, as you said, gotten flack for this paper? I mean, has, what’s the reaction been to these findings?
[00:27:26] Dr Louise King: Well, when I present the research and I presented it many, many national meetings and, and regional meetings, everybody’s very interested and typically presenting to my own colleagues and they wish to know more about how they could help to make change. I’m actually scheduled to present this to colorectal surgeons in the near future.
[00:27:46] And they actually are a bit underfunded themselves if you start comparing between surgical disciplines, but more funded than gynecologic surgery. And so I plan to talk with them about it. I don’t know that many orthopedic [00:28:00] surgeons personally, but the ones that I do know agree with me that orthopedics is very well funded.
[00:28:05] If they would, prefer not to have their discipline decreased in funding. There are some arguments made that orthopedics is more complicated and I would just encourage them to look at some of the videos of the types of surgeries I do. That’s completely inaccurate. Similarly, urologists sometimes would argue that their work is more complicated and I would say the same. But they do have one argument that rings true, right, which is that my training is less. So that would imply that my work is less complicated. And that’s certainly true for those who practice general OBGYN. So one thing I would love to see, and again, I get a lot of flack for this, is a change in how we train our residents.
[00:28:47] And increasing the number of years because for example, in Canada, they have at least one more year and increasing the number of years devoted specifically to surgical training. I think if we’re going to be surgeons, [00:29:00] we need to be trained as surgeons. We need to do it an intern year in general surgery, we need to learn how to operate on the bowel directly, we need to do a lot of things that are not part of our training regimen. Again, I get a lot of flack for that. I think mainly because a lot of people think that would be a good idea, but to operationalize that, we can’t go back and retrain our entire workforce.
[00:29:22] And then adding a year, upsetting the boat there would be incredibly difficult. I can’t even quite wrap my head around what that would look like. And so some of the reluctance just comes from that makes a lot of sense, but how could we possibly do it? Of course we can do it. We just need to figure out how to do it.
[00:29:40] Dr Christopher Robertson: This is a paradigm. This is just a class example of a structural discriminatory problem where, where it’s baked into the entire system. And it’s hard to even conceive the, the, the solutions in the short term, the relationship between additional training and pay is fascinating. This is something that Dr King taught me in the literature sports based on Dr King’s prior research as well,
[00:29:59] that in [00:30:00] the short run the way you get additional training to do gynecological surgeries is to get a fellowship. That’s what we, we currently exist right now and Dr. King is fellow, she’s training today. But ironically, so these would be OBGYNs practicing a general care where their day is spent adjusting birth control or maybe giving primary care to women you know delivering babies.
[00:30:20] And those services are on average better reimbursed than their day that they dedicate to surgery, say once a month. If they want to double down and become a really excellent gynecological surgeon doing that sort of care all day long every day, they go and join a fellowship program. The problem is when they come out of that fellowship program, they’re going to lose about 100, 000 in annual salary because now they’re specializing in the poorly reimbursed care.
[00:30:46] So the, so this is an example of how we’ve got to fix the economics first and then the organization of the profession will follow. So that’s why it’s just critical that we go back upstream to, to get these reimbursement rates changed.[00:31:00]
[00:31:01] Dr Miranda Melcher: So the structural nature of this has been very well explained by the both of you. But where does that leave kind of listeners to this who might be hopefully going, Oh my goodness, I didn’t realize how bad this was. This is not an acceptable situation for us to continue with, but I’m not in charge of the AMA RUC. I am not a member of Congress.
[00:31:22] What can students, people new to the fields of law and justice, or really anyone who might be listening do to help with this?
[00:31:31] Dr Christopher Robertson: Well, let me just say you might have seen the windows behind me went from dark to light because are recording this at six 30 in the morning and I’m so excited that you have a global audience.
[00:31:40] And, and so one thing we actually could do in a future study is, is compare what’s happening in the USA to other countries that are paying their surgeons on a salary, for example, not creating these disparities. So if any of your listeners have access to that data, I think Dr. King’s team and mine would be interested in doing that comparative study to make the case.
[00:31:59] The story we need [00:32:00] to tell is that it needn’t be this way, that there are alternative futures available and so that’s one thing we’re looking to do. Here in America well, we need to, we need to find attorneys willing to bring these cases, we need members of Congress willing to press this issue.
[00:32:15] So those would be the kinds of things. I’ll mention that the third author on our paper was also a student. So this is the way great research works, you know, it’s often intergenerational. Some people say change doesn’t happen, it’s just that old people die and new people come along.
[00:32:28] I think there’s some truth to that saying. So it really is important that the next generation of scholars are also tracking these issues.
[00:32:35] Dr Louise King: Those are excellent suggestions. I think where I could add would be that for those of my colleagues who are interested in this, especially in other disciplines, similarly, right?
[00:32:47] For my colleagues in urology whom I’ve spoken with around the country who agree with me that this is a problem, speak up to your representatives to the AMA RUC. Orthopoedists, I know you’re happy with your [00:33:00] ORs, but please speak up about, you see it, you see the problem, and we really need other people to be a part of it.
[00:33:07] I just wrote a piece for the Hastings Center about that call to action to ask my colleagues in medicine to say, really, we should be fixing our own house and we need to make this right.
[00:33:19] Dr Miranda Melcher: Well, those are lots of different ways for different kinds of people and expertise to get involved and both in the U S and globally. So thank you for sharing that. Is there anything else our listeners should be aware of, of your work coming up, anything they should be looking out for or anything else they should know about this topic?
[00:33:36] Dr Christopher Robertson: Well, I’ll tell you that when I talk to my wife and my mom and my daughter about this issue it actually also affects, now that you know, you do have a little agency in the U. S. to to try to ask hard questions of your physician and consider the level of training and , the surgical volume that you’re getting. So there is, I think, a little bit of patient agency that’s possible as well that I’d recommend thinking [00:34:00] carefully about.
[00:34:01] Dr Louise King: What a great suggestion.
[00:34:02] I always tell any family member and all my patients that you should ask me and any surgeon how long we’ve been in practice, how many of those cases have you done, how many do you do regularly and per month per year, and what is your complication rate. And remember though when you ask about a complication rate, sometimes it will be higher for for better surgeons, but it should still be in the low numbers for any specific procedure that you’re doing because the more complicated the case, the more complication rate could go up.
[00:34:31] But those are appropriate questions to ask of a surgeon. Don’t be scared to ask them. You’re about to go to sleep and let them operate on you, you can ask anything you want and they should be willing to answer.
[00:34:41] Dr Miranda Melcher: Wonderful. Well, thank you both for answering my questions that we have here and for sharing all this information in this format and of course in the paper that will be linked in the show notes.
[00:34:51] Outro
[00:34:51] Dr Miranda Melcher: Thank you so much Christopher and Louise for speaking with us about your research and the article titled [00:35:00] Structural Sex Discrimination, Why Gynecology Patients Suffer Avoidable Injuries and What the Law Can Do About It, published in the Emory Law Journal in 2024.
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