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“Almost every Gynecologic surgeon I know has a story about being told that they were wasting their talent". It was this tweet from US-based gynaecology surgeon Jocelyn Fitzgerald that caught my eye a few months ago. I’m passionate about women’s health and immediately wanted to find out more about how this translated in terms of patient safety. So, in August we met, and Dr. Fitzgerald explained some of the barriers and challenges she faces in delivering safe and equitable care.  Hi Dr Fitzgerald, can you tell us a bit about yourself? I am a double board-certified obstetric gynaecologist, urogynaecologist and pelvic reconstructive surgeon at Magee Women’s Hospital in Pittsburgh. My work includes pelvic floor reconstruction, including vaginal prolapse and urinary incontinence. Other gynaecology surgical specialists include; gynae oncology for cancers of the female reproductive tract, and minimally invasive gynaecology surgery for the treatment of endometriosis and fibroids. What made you want to become a gynaecology surgeon? I knew this was a field that was rife with surgical challenges and inequality – we need the most motivated surgeons and brightest minds! There is so much taboo around what we do that I knew I had to lend my voice. What sort of comments did you get personally, or hear more widely, about gynaecology surgery as a specialty when you were in training? That we are not 'real' surgeons. I've heard that so many times. This definitely had an impact on me personally. All of my peers say the same, that they were told they were wasting their surgical and medical talent by going into Gynaecology. There have even been offensive memes created by anaesthetists and shared widely that imply our specialty is less skilled when in fact sub-specialist gynaecology surgeons have low complication rates, on par or superior to those of other surgical disciplines. How does pay impact talent acquisition? If you train in urogynaecology and want to specialise in surgery you are financially disincentivised to choose the gynaecology route. In the US, we are the lowest paid surgeons in medicine.[1,2] Statistics highlight a double layer of discrimination here, with the highest paid being male clinicians who opt to specialise in urology surgery and the lowest paid being female clinicians who specialise in gynaecology surgery.[3] It feels like we are discouraged from the start to look after women. Coupled with the condescending attitudes to our specialty, poor pay leads to skilled clinicians questioning whether they are too talented to treat women and often choosing a different route. Can you tell us about how clinical services are reimbursed in the US and how this impacts gynaecology surgery? The system here uses something called ‘relative value units’ (RVUs) to determine the amount of money reimbursed to the healthcare provider or organisation for each clinical service provided. A payment formula contains three RVUs, one for physician work, one for practice expense, and one for malpractice expense. Unfortunately, the gap between reimbursement for gynaecology surgeries and other types of surgery continues to widen.[4,5] This disincentivises the recruitment of talent into this high-demand field. In a profit-driven medical environment, it also disincentivises healthcare systems from providing gynaecology surgeons with necessary resources, such as: operating room time facilities staff allocation. It is worth mentioning that only three of the 32 people on the committee that determines RVUs are women.[6] How does this lead to patient harm? This low reimbursement leads to patient harm due to long wait times for surgery, inconsistent staffing, decreased surgeon volume and worse outcomes. Lower reimbursement for gynaecology services compared to obstetrics disincentivises generalist obs/gynaes from providing gynaecology care.[7] This leads them to the majority becoming ‘low volume’ surgeons. Surgeons who operate less are less efficient and have worse outcomes; they lack dedicated teams and repetition, increasing surgery time and subsequent patient harm. Can you give an example of how this plays out for patient care? Endometriosis is a good example. It is a complex disease where tissue similar to the uterine lining is found in the abdominal cavity. It causes significant abdominal and menstrual pain, scarring, and infertility. It takes on average 7-10 years to diagnose due to the vague nature of its symptoms, association with painful menses (which are largely dismissed in emergency settings) and lack of specialist training. Endometriosis surgery is extremely complex and requires fellowship training in advanced gynaecologic Surgery. Only one code exists to reimburse for endometriosis surgery and it makes no distinction between a 20 minute laparoscopy where a lesion was briefly ‘burned’ which typically will achieve minimal benefit, and a five hour excisional procedure.[8] Reimbursement for this complex disease is so low (due to lack of complexity codes and payment) that: patients continue to see unskilled providers some US providers who do have the skills to excise endometriosis will only take cash; bankrupting desperate patients in severe pain women are more likely to face long waits for surgery and/or cancelled operations. See the documentary Below the Belt for a more detailed expose on this topic. What needs to happen to make gynaecology surgery better supported so that all patients have access to safe care? In a profit-driven system here in the US, our procedures need to be coded and reimbursed based on the worth of our skill set. Sub-specialist gynaecology surgeons complete 2-4 years of additional fellowship training in advanced procedures. This is often more than their higher-paid surgeon colleagues, for example orthopaedics, which is 5-6 years of training or Urology, which is 5 years without a fellowship. There needs to be fundamental changes to the RVU system, the involvement of the department of Health and Human Services, and legal options citing gender discrimination, though this would be challenging. Ultimately the discrimination and lack of value for gynaecology surgery is ‘baked in’ to the system and is affecting the level of care women receive. This needs to be addressed at every level to value women and their providers and prevent harm. References Wilcox L. General surgery salary report 2022: Surgeon wages up 8%. Weatherby Healthcare, 2022. Accessed online 25/09/2023. Watson KL, King LP. Double Discrimination, the Pay Gap in Gynecologic Surgery, and Its Association With Quality of Care. Obstet Gynecol. 2021;137(4):657-661. Pelley E, Carnes M. When a Specialty Becomes "Women's Work": Trends in and Implications of Specialty Gender Segregation in Medicine. Acad Med. 2020 Oct;95(10):1499-1506. Polan RM, Barber EL. Reimbursement for Female-Specific Compared With Male-Specific Procedures Over Time. Obstet Gynecol. 2021;138(6):878-883. Benoit MF, Ma JF, Upperman BA. Comparison of 2015 Medicare relative value units for gender-specific procedures: Gynecologic and gynecologic-oncologic versus urologic CPT coding. Has time healed gender-worth? Gynecol Oncol. 2017;144(2):336-342. American Medical Association. Composition of the RVS Update Committee (RUC), 2023. Accessed online 25/09/2023. Watson KL, King LP. Double Discrimination, the Pay Gap in Gynecologic Surgery, and Its Association With Quality of Care. Obstet Gynecol. 2021 Apr 1;137(4):657-661. Seckin T. Historic Update to ICD-10 Endometriosis Diagnosis Codes. Seckin Endometriosis Center, 2022. Accessed 25/09/2023. Share your views Do you work in gynaecology or women’s health in the US or another country? Have you experienced comments or barriers similar to Jocelyn? Is your area of health well resourced and funded? What needs to change to help staff provide safe and equitable care? Please comment below (sign up first for free) or get in touch with us at [email protected] to share your insights.

Anchor institutions are large organisations, connected to their local area, that can use their assets and resources to benefit the communities around them. Health and care organisations, as well as providing healthcare services, are well-placed to use their influence and resources to improve the social determinants of health, health outcomes and reduce health inequalities. This King's Fund event will explore what anchor institutions are, what they look like in practice and how we can embed some of those ways of working within health and care. We will look at how health and care organisations, working in partnership with other local anchor institutions, are leveraging their role as large employers and purchasers of goods and services and playing an active role in protecting the health, wellbeing and economic resilience of their local communities. Register