Medical Specialist Physicians’ EHR In-Basket Workload Differs by Sex: Implications for Compensation and Equity (Preprint)

Background: Prior research has shown that female physicians in primary care receive a higher volume of patient and staff messages in the electronic health record (EHR) in-basket. Objective: We expanded on these findings in this cross-sectional study, assessing gender differences in in-basket messages generated by outpatient care workflows among internal medicine specialists and relative to RVUs - a traditional measure of clinical productivity that can determine compensation for ambulatory physicians. Methods: We collected monthly, ambulatory in-basket physician data and patient characteristics from Epic for January through March 2021 and normalized monthly in-basket burden measures by monthly RVUs. We obtained physician gender, rank, and practice years from the public institutional directory. Specialties were categorized as including a substantial procedural component (cardiology, gastroenterology, pulmonology) versus those predominantly not procedural (genetics, geriatrics, hematology, immunology, infectious disease, nephrology, palliative care, rheumatology, sleep medicine). We compared unadjusted in-basket burden measures by gender using Wilcoxon rank sum tests. To assess persistence of gender differences in in-basket burden after multivariate adjustment, we built models with in-basket burden outcomes as dependent variables; physician sex as the independent variable; and five covariates: physician demographics (academic rank, practice years); patient characteristics (age, problem number); and panel size (number of unique patients each physician evaluated and managed in each month). We excluded physicians with incomplete covariate data to more reliably calculate per-RVU workload measures. We performed likelihood ratio and bootstrapping tests to assess gender effect in a first model with all specialties, and in a second model with predominantly procedural specialties excluded. Results: We found that female physicians in internal medicine specialties spent more time on all in-basket activities and received a higher number of staff and patient messages per RVU. Conclusions: Women physicians in ambulatory medical specialties face a greater burden of in-basket work per every unit of paid clinical care. Clinical Trial: Not applicable