Caution urged in interpreting study findings

I read with interest “Association between family physician gender and patient service times. Evidence from Ontario”¹ by Kralj et al in the January 2026 issue of Canadian Family Physician. The article examined associations between family physician gender, patient encounter duration, and income implications under fee-for-service remuneration. The topic is timely and relevant; however, several methodological and interpretive considerations merit further discussion.

The primary outcome measure, time spent per patient, was derived from self-reported survey data rather than objective sources such as electronic medical records or direct observation. Self-reported estimates are susceptible to recall and reporting biases, which may be non-differential or systematic. Given that relatively small differences in encounter duration were extrapolated to substantial annual income estimates, the absence of objective validation is a notable limitation.

Additionally, the analysis does not adequately account for patient case mix or visit complexity. Encounter length in family medicine is strongly influenced by multimorbidity, psychosocial burden, and visit purpose. Without adjustment for these factors, it is difficult to attribute observed differences primarily to physician gender, rather than to characteristics of patient panels or practice styles.

The interpretation of findings using terminology such as “gender pay gap,” together with suggested policy implications,¹ implies a causal relationship that cannot be established within a cross-sectional study design. While associations are clearly demonstrated, causality remains uncertain, and alternative explanations related to practice preferences, remuneration models, or scheduling patterns have not been fully explored.

Furthermore, extrapolations estimating an annual income difference of approximately $45,500 assume uniformity in practice volume, billing patterns, and working hours, which may not reflect the heterogeneity of contemporary family medicine practice.

Finally, the study does not assess patient-level outcomes. Without examining whether longer encounters translate into improved care quality, continuity, or downstream health system utilization, conclusions regarding efficiency or disadvantage remain incomplete.

In conclusion, while the study raises important questions about how physician time is valued, methodological limitations and unmeasured confounders suggest that caution is warranted in interpreting the findings as evidence of gender-based income inequity. Future research incorporating objective encounter data, case-mix adjustment, and patient outcomes would strengthen the evidence base for policy reform.

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