Female Surgeons Hold Slight Edge Over Male Peers in Terms of Patients’ 30-Day Mortality
That results were largely similar for both sexes could inform discussions on diversity in a field traditionally dominated by men, researchers say.
Female and male surgeons achieve similar surgical outcomes, including complication and hospital readmission rates, but women come out a little bit ahead by virtue of offering a 12% relative reduction in 30-day mortality for their patients.
The findings were derived from a 9-year period in Ontario, Canada, and included the experiences of about 3,300 surgeons performing 25 different types of surgery, among them CABG, femoral-popliteal bypass, and abdominal aortic aneurysm repair.
Results were published online October 11, 2017, ahead of print in BMJ.
While the investigators describe the differences as small and stress that the reasons for them are unclear, they also speculate on why female surgeons, who made up 23.4% of the cohort, might in fact be performing better than their male peers.
“Women undertaking a surgical career experience barriers in training and in practice,” Christopher J.D. Wallis, MD (Sunnybrook Health Sciences Center, Toronto), and colleagues write. “Previous work has shown that ‘surgical personality,’ surgical culture, and sex-based discrimination, as well as lifestyle factors and workload, are deterrents for women considering a career in surgery. Difficulty identifying mentors, owing to the lack of women in leadership positions in surgery, might exacerbate this problem.”
As a whole, such “barriers might create a higher standard for women to gain entrance into the surgical workforce than men, resulting in the selection of a cohort of women that are proportionately more skilled, motivated, and harder working,” they suggest.
What can I learn from my female colleagues? Christopher J.D. Wallis
To TCTMD, Wallis said that for surgeons, step one is acknowledging the historical barriers faced by women in medicine.
“These data strongly support the fact that female surgeons do not deserve to be seen in any less of a light than their male counterparts,” he stressed. Along with data published last year in JAMA Internal Medicine, Wallis added, the new study confirms “women are at least as good as men and potentially somewhat better, although the absolute effect size is quite small.”
As a man who practices surgery, Wallis said, step two for him involves asking questions: “What can I learn from my female colleagues? If women are getting better outcomes and their patients do better, what can I learn from what they’re doing to change my practice? How can I evolve to get the best care for my patients?”
Senior author Raj Satkunasivam, MD (Houston Methodist Hospital, TX), agreed, noting that the point isn’t to “dwell on” whether women outperform men. Rather, he told TCTMD, it’s better to ask if there are certain things about the way female surgeons practice surgery that merit a closer look, such as “the manner in which they communicate, the way in which they utilize guidelines and follow them, their risk-taking behavior.”
Learning lessons from these patterns not only will improve the way medicine is currently done, he added, “but also, importantly, instill it in the next generation—ie, the way that we train surgical residents and potentially even the way we train medical students.”
Matched Comparison: Women vs Men
Out of an initial data set of more than 1.1 million patients undergoing surgery, Wallis et al matched 104,630 cases from Ontario involving female and male surgeons balanced for procedure type, patient age and sex, comorbidity, surgeon volume, surgeon age, and hospital. Surgeries took place between 2007 and 2015.
Overall, patients operated on by women were at lower risk of experiencing the composite outcome of death, hospital readmission, or complications within 30 days (11.1% vs 11.6%; adjusted OR 0.96; 95% CI 0.92-0.99). But among those three endpoints, the only comparison where female operators held the advantage was for 30-day mortality (adjusted OR 0.88; 95% CI 0.76-0.99).
There were no sex-outcome differences when researchers looked only at emergency surgeries, for which patients aren’t choosing whether a woman or man will treat them. For elective cases, though, there was a reduction in the composite outcome with female versus male surgeons (adjusted OR 0.94; 95% CI 0.89-0.98).
In nonemergency cases, it may be that “certain kinds of patients are picking female surgeons,” Wallis said. “Another explanation is that part of the reason why patients who are treated by female surgeons do better is that [they provide] better patient selection or preoperative management in elective cases,” which wouldn’t happen in emergency cases. The disparity may also come down to differences in case mix across specialties and by gender, he added.
‘Supporting Sex Equality and Diversity’
The investigators emphasize their results shouldn’t encourage patients to choose surgeons based on sex. Instead, the study should encourage efforts to better understand which “mechanisms related to physicians and the underlying processes and patterns of care” might affect outcomes, they suggest in their paper.
“Our findings have important implications for supporting sex equality and diversity in a traditionally male-dominated profession,” Wallis and colleagues conclude.
An editorial accompanying the paper, by Clare Marx, MBBS, and Derek Alderson, MD (The Royal College of Surgeons of England, London), agree that the “study helps to combat . . . lingering biases by confirming the safety, skill, and expertise of women surgeons relative to their male colleagues.”
They, too, express reservations over how the results should be applied.
“Improving surgical outcomes is a complex undertaking. Surgeons and researchers tend to focus on physical and clinical endpoints, often failing to acknowledge the importance of the social and emotional outcome after surgery. Hospital providers are more concerned with cost-effectiveness and efficiency savings than community costs,” Marx and Alderson explain.
“With so many critical factors to consider, trying to find out why there is a very small difference in short-term clinical outcomes between male and female surgeons is unlikely to prove worthwhile,” they say. “Nor are we convinced that the sex of the surgeon will emerge as an important determinant of a good outcome for patients having surgery.”
Wallis CJD, Ravi B, Coburn N, et al. Comparison of postoperative outcomes among patients treated by male and female surgeons: a population based matched cohort study. BMJ. 2017;359:j4366.
Marx C, Alderson D. Improving patient outcomes after surgery: the sex of the surgeon is unlikely to be relevant. BMJ. 2017;359:j4580.
- Wallis, Satkunasivam, Marx, and Alderson report no relevant conflicts of interest.