Patients treated by female surgeons have lower rates of adverse postoperative long-term outcomes – including death – than similar patients treated by male surgeons, and were less likely to suffer complications, according to recent findings, which defined “long-term” as any outcome within 90 days or within a year.
The study builds on previous research that had similar findings about patient outcomes related to the sex of the surgeon, but within 30 days, the traditional time period used to examine surgical outcomes, including in the National Surgical Quality Improvement Programme.
“In recent years, surgeons have come to appreciate that the effects of surgery can linger for longer than 30 days,” said Christopher Wallis, first author and urologic oncologist at Mount Sinai Hospital and University Health Network in Toronto.
“Outcomes that are longer are much more about the thought process and the whole overall care pathway delivered to a patient. And so I think that’s why it’s important to complement 30 day outcomes with longer outcomes.”
STAT News reports that researchers examine data that included more than 1m patients who underwent one out of 25 possible common elective or emergent surgeries.
A total of 151 054 of them were treated by a female surgeon and 1 014 657 by a male surgeon. The population-based retrospective cohort study was conducted in adults in Ontario, Canada, who had surgeries between 2007 and 2019.
Patients treated by male surgeons were 25% more likely to die within 90 days, and 24% more likely to die within a year compared with patients treated by female surgeons.
Similarly, patients treated by male surgeons were 5% more likely to be readmitted to the hospital within 90 days, and 4% more likely to be readmitted within a year. And patients were 9% more likely to experience complications within 90 days and within a year.
Even though female surgeons were a smaller subset – with 700 female surgeons being compared with 2 306 male surgeons – a difference was still seen, which paper co-author Angela Jerath found impressive.
“The way the analysis is done is that even though women form a smaller subset here, the patients have been matched in a way that they look as similar as we can make them, whether being operated on by a male and female surgeon, and you still see this difference,” said Jerath, a cardiac anaesthesiologist at Sunnybrook Health Sciences Centre and an associate professor at the University of Toronto.
Wallis clarified that while patients were not directly matched, unlike in the previous study from 2017, statistical modelling techniques are used to account for differences in patient, surgeon, anaesthesiologist, procedure and hospital factors.
Researchers also found that while in general patients had better outcomes with female surgeons, female patients – when treated by male surgeons – fared far worse than expected and had higher rates of adverse postoperative events within a year.
What are women doing differently?
It probably has to do with what surgeons are doing outside the operating room. By looking at specific traits that have an impact on care, Jerath said, everyone in the health care system can benefit.
“It’s not because females are technically better surgeons,” said Cassandra Kelleher, an associate professor of surgery at Harvard Medical School and paediatric surgeon at Massachusetts General Hospital, who was not involved in the research, which was published in JAMA Surgery.
“It’s because somehow women may be preparing patients for surgery better, as suggested by their elective patients having better outcomes than emergent patients.”
Kelleher speculated that maybe female surgeons are also discussing what postoperative care might look like, so patients can adhere to those recommendations, or they’re listening to patients more after surgery.
“There’s something qualitatively different about the kind of practice that female surgeons have,” she said.
Prior studies have shown that there is concordance between practice style and physician-patient communication, which can affect patient outcomes for male and female physicians. “The novelty of our work is showing that these known differences in practice pattern translate to clinical outcomes for patients,” Wallis said.
“The most poignant point about this (study), I think, is their concluding statement, which is to provide the best patient care, organisations should not only support women physicians but they need to learn how women are accomplishing these better outcomes,” Kelleher said.
In the future, the researchers will look at other aspects of the patient care pathway, which includes other members of the health care team, like residents, nurses, social workers and other support staff to see how that might affect patient outcomes.
Among the study’s limitations, the research team was not able to account for race and ethnicity, professional hierarchy, years of experience, training, or case complexity because of limited data.
They also could not account for other team members, like nurses and residents, whose roles also have an impact on patient care.
“I think the focus should be on bringing more female surgeons into the fold, increasing the diversity within surgery as a whole, not just from a gender standpoint, but from making our surgical workforce look more like our patient population that we serve,” said Catherine Sharoky, an assistant professor of surgery at the University of Pennsylvania who also works in the division of traumatology, surgical critical care, and emergency surgery, who was also not involved with the study.
Sharoky’s 2018 study, aptly called “Does Surgeon Sex Matter?” looked at the difference in practice style between male and female surgeons, who had similar cases, the same amount of clinical experience at the same hospitals, and treated similar patients, and found that patient outcomes were equivalent.
Kelleher agreed, adding that people who have unique perspectives and unique life experiences could bring different perspectives to caring for patients and improving outcomes.
“It’s not personal. It’s not man versus woman. It’s not technical skill or… prowess or anything. It’s just another tool to take better care of patients.”
Study details
Surgeon Sex and Long-Term Postoperative Outcomes Among Patients Undergoing Common Surgeries
Christopher Wallis, Angela Jerath, Khatereh Aminoltejari, et al.
Published in JAMA Surgery on 30 August 2023
Abstract
Importance
Sex- and gender-based differences in a surgeon’s medical practice and communication may be factors in patients’ perioperative outcomes. Patients treated by female surgeons have improved 30-day outcomes. However, whether these outcomes persist over longer follow-up has not been assessed.
Objective
To examine whether surgeon sex is associated with 90-day and 1-year outcomes among patients undergoing common surgeries.
Design, Setting, and Participants
A population-based retrospective cohort study was conducted in adults in Ontario, Canada, undergoing 1 of 25 common elective or emergent surgeries between January 1, 2007, and December 31, 2019. Analysis was performed between July 15 and October 20, 2022.
Main Outcomes and Measures
An adverse postoperative event, defined as the composite of death, readmission, or complication, was assessed at 90 days and 1 year following surgery. Secondarily, each of these outcomes was assessed individually. Outcomes were compared between patients treated by female and male surgeons using generalised estimating equations with clustering at the level of the surgical procedure, accounting for patient-, procedure-, surgeon-, anaesthesiologist-, and facility-level covariates.
Results
Among 1 165 711 included patients, 151 054 were treated by a female and 1 014 657 by a male surgeon. Overall, 14.3% of the patients had 1 or more adverse postoperative outcomes at 90 days and 25.0% had 1 or more adverse postoperative outcomes 1 year following surgery. Among these, 2.0% of patients died within 90 days and 4.3% died within 1 year. Multivariable-adjusted rates of the composite end point were higher among patients treated by male than female surgeons at both 90 days (13.9% vs 12.5%; adjusted odds ratio [AOR], 1.08; 95% CI, 1.03-1.13) and 1 year (25.0% vs 20.7%; AOR, 1.06; 95% CI, 1.01-1.12). Similar patterns were observed for mortality at 90 days (0.8% vs 0.5%; AOR 1.25; 95% CI, 1.12-1.39) and 1 year (2.4% vs 1.6%; AOR, 1.24; 95% CI, 1.13-1.36).
Conclusions and Relevance
After accounting for patient, procedure, surgeon, anaesthesiologist, and hospital characteristics, the findings of this cohort study suggest that patients treated by female surgeons have lower rates of adverse postoperative outcomes including death at 90 days and 1 year after surgery compared with those treated by male surgeons. These findings further support differences in patient outcomes based on physician sex that warrant deeper study regarding underlying causes and potential solutions.
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