Fixing the System Behind the Symptom: A Case Study in Structural Change
Photo by Marek Studzinski on Unsplash
In 2023, a team of Canadian physicians published a study in the Canadian Journal of Surgery asking a direct question: does it pay less to operate on a woman than on a man?
Chaikof and colleagues built a list of matched surgeries — procedures that are roughly equivalent in complexity, time, and training required, but performed on female versus male anatomy. Then they compared what provincial health plans actually paid for each one.
Across most of the provinces studied, surgeons were paid meaningfully less for procedures done on women — 26.7% less, on average. Saskatchewan showed the largest gap in the country, at 67.3%. British Columbia was close behind at 61.2%.
The pattern behind the numbers
It would be easy to read that finding as a list of prices that need updating. But the researchers pointed to something deeper: fee schedules aren't set all at once. They're divided up among specialty groups, each of which controls a slice of the budget and negotiates its own codes over time. There's no ongoing check anywhere in that process asking whether the pattern being created adds up to something unfair.
This is a structural problem. Nobody has to decide, on purpose, to undervalue care for women — it can happen simply because no one is watching for it. And because nothing in the process catches it, it doesn't correct itself. It just gets renegotiated again, the same way, next cycle.
What a real fix looks like
So how do we make sure that doctors are paid equitably for surgery performed regardless of gender? One might be tempted to focus on the individual doctors and their salaries, but this issue isn’t going to be solved on an individual level, it must address the system.
Start by extending the study's own method — the matched-procedure audit — across a province's entire relevant fee schedule. A panel of physicians, working the same way the original research team did, identifies every pair of comparable procedures and documents the current gap in full.
Then take that audit to the body that actually sets the fees. In Saskatchewan, after the study made headlines, the provincial medical association's leadership publicly called their own numbers "unacceptable" and said they intended to act. Partnering with willing institutions is a solid step in the right direction toward making a change.
What Changes could be made to address the Structural Failure?
A standing Sex-Based Fee Equity Review, written into the association's negotiation procedures as a required step every time fees go up for renewal with the Ministry of Health. And a formal indexing rule requiring percentage increases to be applied in a way that actually closes the dollar gap over time. Once it's in the governance documents, it doesn't depend on any one champion, this year's leadership, or public attention staying high. It gets built into the system and runs, every cycle, because it's part of the process now.
A formal, documented rule for how the overall fee envelope gets distributed across sections, correcting for the historical undervaluation of female-predominant specialties like OB/GYN.
This Audit methodology and review protocol could be taken to the Canadian Medical Association or a similar national body for adoption as a recommended model policy.
The provincial medical association or ministry could commit to publishing an annual report on fee-code parity by sex — making the data public on an ongoing basis instead of relying on outside researchers to periodically re-run the audit.
Evaluating whether it worked
Effective evaluation is built in at the very beginning of a project. It determines what to measure, and how you plan to do it.
A credible evaluation for a project like this has to track a specific kind of evidence:
Was a written policy actually adopted, requiring this equity review going forward?
Did the institution actually use it, the next time fees were up for negotiation?
Did the underlying gap — the real dollar difference between matched procedures — measurably shrink when the numbers were checked again later?
In complex structural projects, there can be many variables that can contribute to their success or failure. Therefore, we must ask, if after the project has finished, and has had the intended consequences: how do we know it was the project that caused it?
Public attention on this issue was already building on its own by the time any project like this could start. If the pay gap narrows, was it because of the new standing process — or would pressure and headlines have produced this result anyway?
Evaluating this properly means confronting that question directly. A rigorous evaluation builds in, from the start, an honest comparison against what would probably have happened anyway — and reports its findings as a real range, with the uncertainty left visible. That's what separates evaluation that's genuinely useful from a document that just makes a project look good.
In conclusion
Structural problems get solved by fixing the process that keeps producing the same unacceptable results. In this case, a significant discrepancy in what surgeons were paid for procedures done on women. It will take a concentrated effort of gathering and sharing data, partnering with institutions, implementing the changes and continued monitoring to ensure it moves from gathered data to lasting change.
