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Surgical Outcomes Worse for Women When Doctor is Male

Feb. 8, 2022 - Todd Ackerman

Female patients are more likely to experience adverse surgical outcomes when the procedure is performed by a man than a woman, according to a Houston Methodist-led study that digs deeper into how the gender gap affects medical care.

The study, which looked at 1.3 million adult patients in Canada over a 12-year period, found that women are 15% more likely to suffer a complication, 11% more likely to require readmission and 32% more likely to die when they were operated on by a male doctor rather than a female doctor.

"The findings were very surprising to me," says Dr. Raj Satkunasivam, a Houston Methodist professor of urology and the study's senior author, in collaboration with the University of Toronto's Dr. Christopher Wallis. "I would have never anticipated such statistically and clinically significant differences in outcomes as we identified."

Despite the discrepancy by gender, the study showed the vast majority of patients did well after surgery. All told, 85% of patients had no adverse outcomes whatsoever. The study found no difference in adverse outcomes in male patients treated by surgeons of either sex.

Dr. Satkunasivam acknowledged certain limits to the study. He noted that the team didn't have the necessary data to control for the complexity of certain surgeries — say, one appendectomy versus another or one difficult cancer case versus another.

Dr. Satkunasivam believes the reason for the adverse surgical outcomes may be related to communication styles with patients and collaboration with colleagues, things that previously have been demonstrated to differ between female doctors and male doctors. The underlying cause may not be due to differences in surgical prowess or technical skill.

First-of-its-kind study

The study, published Dec. 8, 2021, in JAMA Surgery, is the first of its kind to examine the relationship between the patient's sex, the surgeon's sex and the surgical outcome. It included more than 2,900 surgeons, 82% of whom were male and 18% of whom were female. Nearly 46% of patients were the same sex as their surgeon.

Investigators compared adverse postoperative outcomes — complications, readmissions and deaths — within 30 days of 21 types of gender-neutral elective and emergency surgeries. Surgeries ranged from common operations like hip and knee replacements, bariatric surgery and the removal of an appendix or gall bladder to more complicated procedures such as a heart bypass, aneurysm repair and brain surgery.

The study builds on previous research Dr. Wallis and Dr. Satkunasivam led with Canadian patients that found patients of female surgeons generally tend to have lower death rates, fewer complications and lower readmissions. The findings, thereafter replicated in Medicare patients by another team of researchers, triggered a national conversation about medicine's gender gap.

Dr. Satkunasivam says the new study's insights accounted for some of the previous work's findings, but doesn't explain all of it.

The new study widened and updated the patient cohort from the original study. Every patient received care from a single government payer, the Ontario Health Insurance Plan.

The government records enabled Dr. Satkunasivam's team to match by age and years in the field and control for the fact that male surgeons on average tend to have more experience than female surgeons. More experience typically results in better outcomes, but not always, especially when it leads the surgeon to take on more difficult cases.

Study sounds the alarm for urgent action

Dr. Satkunasivam says the study findings underscore the need for follow-up research into the reasons for the outcome differences. He theorized, for example, that male surgeons may view seeking colleagues' input into a patient's care as a weakness and that female surgeons may be more open to involving others in troubleshooting a problem. He says such an attitude may put patients' treatment by female surgeons less at risk of "failure to rescue" by spotting issues earlier in the disease process or saving patients from serious complications in the postoperative period.

In an accompanying editorial in JAMA Surgery, University of Florida Drs. Andrea Riner and Amalia Cochran wrote that "the association between surgeon-patient sex discordance and outcomes sounds the alarm for urgent action." They called for further investigation and immediate action.

Dr. Satkunasivam's team is currently looking at interactions between anesthesiologists and surgeons, and whether gender plays a role in how they work together.

Drs. Riner and Cochran also wrote that "the elephant in the room is the paucity of female surgeons." Though the numbers have increased in recent years, women make up just 22% of U.S. surgeons.

"I think one takeaway from this study is we all stand to benefit from understanding what it is that female surgeons are doing that may be leading to better outcomes," says Dr. Satkunasivam. "Male surgeons still provide excellent care, but it's important to figure out if behavioral and communication styles affect outcomes and, if so, push it into training programs to try and improve the care of all patients."

Researchers at George Washington University, the Medical College of Georgia and Vanderbilt University collaborated with Houston Methodist and the University of Toronto on the study. They included Dr. Barbara Bass, currently dean of George Washington's School of Medicine and Health Sciences, and who served as Houston Methodist's chair of surgery from 2005-2019 — one of just a handful of women in the nation at the time to rise to such a level.

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Surgical Case