Family physician pay inequality: a qualitative study exploring how physician responses to perceived patient expectations may explain gender, race, and immigration status pay differences

BACKGROUND: Pay inequality related to social identity has been observed among physicians, even after accounting for hours worked and specialty. Physician identity factors, such as gender and race, may contribute to practice behaviours in ways that affect income. In this study, we sought to explore how Ontario family physicians understand the relation between their identities and practice patterns and to form a theory of how identities may influence practice decisions in ways that result in income disparities. METHODS: We conducted a constructivist grounded theory study to understand how social identities affect income discrepancies among physicians. We conducted interviews with family physicians practising in Ontario. Physicians were purposively and then theoretically sampled for variation on several identity factors. We staged the analysis using constant comparative techniques. RESULTS: Fifty-five family physicians participated. The analysis identified physician perception of patient expectations as a key factor influencing income. Based on the interviews, we developed a 4-stage theory to explain this mechanism: physician understanding of patient expectations, the nature of the expectations, physician responses to those expectations, and financial implications of those responses. We illustrate this theory with data from 2 frequently occurring examples: how physician gender influences income via patient expectations, and how physician culture, language, and immigrant or nonimmigrant status influence income via patient expectations. INTERPRETATION: Patient-centred care requires individualized approaches, yet common physician remuneration models fail to account for the time needed to provide these meaningful interactions. This dynamic may create structural disincentives for physicians who provide relational, emotionally intensive, or culturally tailored care, potentially reinforcing income disparities related to social identities.