Commentary on: Gender Disparity in 2013-2018 Industry Payments to Plastic Surgeons

The Physician Payment Sunshine Act established in 2010 requires drug/device manufacturers to disclose payments to physicians. The Centers for Medicare and Medicaid Services makes these data public through the Open Payments Database (OPD), which was started in 2014. This galvanized attention and has resulted in numerous publications about the distribution of the industry’s money, the impact of this on the practice of physicians, and conflicts of interest.

One consistent finding is that women physicians receive substantially lower industry payments than men. In the surgical specialties, similar proportions of female and male surgeons receive funding, but women receive lower sums. This study confirms this in plastic surgery. Women comprise 16% of American Society of Plastic Surgeons membership, and the OPD database records 16.7% of payments in plastic surgery went to women. The big differential is in the dollar amount of the payments, and this study reports that men make twice as much as women. One of the problems with this conclusion is the extreme bias due to the huge sums going to only 1% of plastic surgeons and the statistic that $16,400,200.00 was paid to 1 male. It would be instructive to see the funds distribution among the other 99% of plastic surgeons because this would provide better insight into the level of gender differences outside the small number of the top 1% earners.

The gender disparity in the dollar amount of industry funding per capita has been reported in orthopedics, otolaryngology, urology, neurosurgery, and other several medical specialties as well as plastic surgery. There are different ways funds flow to physicians, including research funding, speaker fees, education fees, and consulting fees. Males make higher proportions in all of these categories. Although there is much speculation about why this is the case, causation is not clear. It is speculated that women in academic plastic surgery receive lower payments because they are more junior and have not had time to reach the rank, productivity, and experience of male colleagues. This is supported by the statistic that women plastic surgeons constitute 35% of all residents but only 14% of full-time academic faculty, but it is refuted by the statistic that men consistently receive more industry funding than women at every level of academic ranking even when controlling for time in practice.¹

It may be helpful to look more specifically at the breakdown of the type of payments made by industry. One of the highest value industry payments to plastic surgeons is for speaker-related activities. Serving as faculty or speaker at industry-sponsored educational and training venues other than continuing education programs accounted for 48% of the total payments made by 1 manufacturer in the plastic surgery market. That manufacturer reported a total payment amount of $9.9 million dollars to plastic surgeons in 2018.² The magnitude of this specific type of compensation may be relevant to the gender disparity. Women comprise about 14.8% of speakers at plastic surgery meetings, including instructors, moderators, and panelists.³ The proportion of male and female speakers at industry-sponsored events is unreported, but one could wonder whether the proportion is similar and whether individual payments are independent of gender. Because the female plastic surgeon demographic is younger, perhaps invitations to speak at industry venues go to the more numerous, older, male plastic surgeons who may have greater experience with the manufacturers’ products and devices.

There needs to be a deeper, more detailed look into the specifics of industry payments for consultants, for the general recipients of gifts, and for the distribution of research dollars. Better information may help to explain the numbers drawn in broad brush strokes in this paper. However, it is important to remember that there is also constant and pervasive unfairness in physician compensation. What studies show about inequities in industry payments is parallel with numerous studies showing a consistent and meaningful difference in the earning power of male and female physicians. After accounting for all the factors in academic medicine that might explain a salary difference such as faculty rank, choice of specialty, NIH funding, participation in clinical trials, and publication count, there remains an unexplained salary inequity. One might speculate that this is different in private practice. However, after adjusting for hours worked, choice of specialty, and geographic location, female physicians earn $1 for every $1.25 male physicians earn. As of 2018, there was no physician specialty in which women earned more than men. Even in specialties dominated by women, such as obstetrics-gynecology, the salary inconsistences favoring men exist.⁴

Other important features brought to light in this paper are the ubiquity of industry payments to plastic surgeons (82% of American Society of Plastic Surgeons members) and the magnitude of the payments from industry to some plastic surgeons. The paper specifically excludes research payments and ownership interests, which could be considered part of research and development. Instead, it covers speaker fees, food and beverage, and the category of “gifts.” These are items that influence purchasing decisions by increasing brand recognition and utilizing motivated speakers to promote utilization of the product. Although gifts and subsidies from manufacturers may foster medical education and provide welcome perks, they compromise the objectivity of a physician’s decision-making. This has been shown repeatedly and gave rise to the demand for financial transparency within the medical profession, which has included the creation of the OPD that provided the data employed in this study. Within plastic surgery, long-standing conflict of interest policies have evolved to current requirements for disclosure of the actual dollar amount a speaker has received on a slide at many professional meetings.

The authors of this paper should be complimented for bringing attention to 2 important issues in plastic surgery:⁵ the compensation disparities faced by women plastic surgeons, and the risk of potential bias arising from industry relationships that are not made apparent during product discussions.

Disclosures

The author declared no potential conflicts of interest with respect to the research, authorship, and publication of this article.

Funding

The author received no financial support for the research, authorship, and publication of this article.

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