A study in JAMA Surgery shows that women have a 15% greater chance of death or serious injury if a man, rather than a woman, operates on them.
The researchers from Vanderbilt University in Nashville, Tennessee, and the University of Toronto in Canada, investigated the likelihood of either death or severe complications based on the gender of their surgeons, and showed that when women operated on women, men on men, or women or men, there was no increased risk of death or other complications.
However, when men operate on women, the patient has a 15% increased chance of either dying or suffering another negative outcome.
The researchers cannot explain why this happens, saying further research is needed into why being operated on by a man is more dangerous for a female patient.
“What is surprising and troubling is that negative outcomes, including complications and death, were linked to sex discordance,” wrote Dr Amalia Cochran, a surgeon at the University of Florida, in a research letter.
“Unfortunately, this association disproportionately affected female patients. The association between surgeon-patient sex discordance and outcomes sounds the alarm for urgent action.”
The research team gathered data from 180,000 surgeries, both elective and emergent, in Canada from November 2020 to March 2021. Of that group, 717,548 were ‘sex discordant’, when the surgeon and the patient are different genders.
More than 667,000 were male surgeons operating on women, and 50,000 were females being operated on by men.
About 15% of the 180,000 procedures ended in a patient either dying, or suffering another major complication as a result.
Researchers then controlled the data for other factors that could cause a person to suffer complications from surgery, like the type of operation, age, and conditions the patient might have suffered.
After adjustments, they found that there was no increased risk of death or other complication when the surgeon and patient were both the same gender.
There was also no increased risk when the physician was a woman who was operating on a man.
When a male operated on a woman, though, the overall risk would sharply increase 15%.
Cochran notes that the reasons for this are not understood, but a way to instantly prevent negative surgical outcomes for women is to close the gender gap in the number of surgeons in America.
“Although the underlying reasons for this disparity are not fully understood, which warrants further investigation, action should be taken immediately,” she said. “The elephant in the room is the paucity of female surgeons.
“In 2019, only 22% of general surgeons in the US were women, and orthopaedic surgery had the lowest representation of female surgeons.”
She added that current surgeons should reflect on their own work, and make sure they were not providing women with subpar care.
“Self-reflection is warranted on the way in which we provide care. Surgeons probably believe they provide the same quality of care to patients irrespective of identity,” she continued. “However, these data underscore an under-appreciated phenomenon and highlight a measurable repercussion of implicit bias.”
Cochran added that hospital leadership could take action, and include metrics about how a surgeon performed, based on their patient’s gender in workplace reviews.
She also recommended sensitivity training in surgeons to uncover the problem causing these disparities, and root it out.
Study details
Association of Surgeon-Patient Sex Concordance With Postoperative Outcomes
Christopher Wallis, Angela Jerath, Natalie Coburn, Zachary Klaassen, Amy Luckenbaugh, Diana Magee, Amanda Hird, Kathleen Armstrong, Bheeshma Ravi, Nestor Esnaola, Jonathan Guzman, Barbara Bass, Allan Detsky, Raj Satkunasivam.
Published in JAMA Surgery online on 8 Decemer 2021
Key Points
Question What is the association of surgeon and patient sex concordance with postoperative outcomes?
Findings In this population-based cohort study of 1,320 108 patients treated by 2,937 surgeons, sex discordance between surgeon and patient was associated with a small but statistically significant increased likelihood of adverse postoperative outcomes. This was driven by worse outcomes for female patients treated by male physicians without a corresponding association among male patients treated by female physicians.
Meaning This study found that sex discordance between surgeons and patients (particularly male surgeons and female patients) may contribute to worse surgical outcomes.
Abstract
Importance
Surgeon sex is associated with differential postoperative outcomes, though the mechanism remains unclear. Sex concordance of surgeons and patients may represent a potential mechanism, given prior associations with physician-patient relationships.
Objective
To examine the association between surgeon-patient sex discordance and postoperative outcomes.
Design, Setting, and Participants
In this population-based, retrospective cohort study, adult patients 18 years and older undergoing one of 21 common elective or emergent surgical procedures in Ontario, Canada, from 2007 to 2019 were analysed. Data were analysed from November 2020 to March 2021.
Exposures
Surgeon-patient sex concordance (male surgeon with male patient, female surgeon with female patient) or discordance (male surgeon with female patient, female surgeon with male patient), operationalised as a binary (discordant vs concordant) and 4-level categorical variable.
Main Outcomes and Measures
Adverse postoperative outcome, defined as death, readmission, or complication within 30-day following surgery. Secondary outcomes assessed each of these metrics individually. Generalised estimating equations with clustering at the level of the surgical procedure were used to account for differences between procedures, and subgroup analyses were performed according to procedure, patient, surgeon, and hospital characteristics.
Results
Among 1, 320 108 patients treated by 2,937 surgeons, 602,560 patients were sex concordant with their surgeon (male surgeon with male patient, 509,634; female surgeon with female patient, 92,926) while 717,548 were sex discordant (male surgeon with female patient, 667,279; female surgeon with male patient, 50,269). A total of 189, 390 patients (14,9%) experienced one or more adverse postoperative outcomes. Sex discordance between surgeon and patient was associated with a significant increased likelihood of composite adverse postoperative outcomes (adjusted odds ratio [aOR], 1,07; 95% CI, 1,04-1,09), as well as death (aOR, 1,07; 95% CI, 1.02-1,13), and complications (aOR, 1,09; 95% CI, 1.07-1.11) but not readmission (aOR, 1,02; 95% CI, 0.98-1,07). While associations were consistent across most subgroups, patient sex significantly modified this association, with worse outcomes for female patients treated by male surgeons (compared with female patients treated by female surgeons: aOR, 1,15; 95% CI, 1,10-1,20) but not male patients treated by female surgeons (compared with male patients treated by male surgeons: aOR, 0,99; 95% CI, 0,95-1,03) (P for interaction = .004).
Conclusions and Relevance
In this study, sex discordance between surgeons and patients negatively affected outcomes following common procedures. Subgroup analyses demonstrate that this is driven by worse outcomes among female patients treated by male surgeons. Further work should seek to understand the underlying mechanism.
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