• JAMA surgery · Dec 2021

    Association of Surgeon-Patient Sex Concordance With Postoperative Outcomes.

    Female patients treated by male surgeons more commonly experience post-operative complications and death than when treated by female surgeons.

    pearl
    • WallisChristopher J DCJDDepartment of Urology, Vanderbilt University Medical Center, Nashville, Tennessee.Division of Urology, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.Division of Urology, Department of Surgery, Mount Sinai H, Angela Jerath, Natalie Coburn, Zachary Klaassen, Amy N Luckenbaugh, Diana E Magee, Amanda E Hird, Kathleen Armstrong, Bheeshma Ravi, Nestor F Esnaola, Jonathan C A Guzman, Barbara Bass, Allan S Detsky, and Raj Satkunasivam.
    • Department of Urology, Vanderbilt University Medical Center, Nashville, Tennessee.
    • JAMA Surg. 2021 Dec 8.

    ImportanceSurgeon 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.ObjectiveTo examine the association between surgeon-patient sex discordance and postoperative outcomes.Design, Setting, And ParticipantsIn 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 analyzed. Data were analyzed from November 2020 to March 2021.ExposuresSurgeon-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), operationalized as a binary (discordant vs concordant) and 4-level categorical variable.Main Outcomes And MeasuresAdverse postoperative outcome, defined as death, readmission, or complication within 30-day following surgery. Secondary outcomes assessed each of these metrics individually. Generalized 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.ResultsAmong 1 320 108 patients treated by 2937 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 1 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 RelevanceIn 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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    This article appears in the collection: Effect of doctor gender & age on patient outcomes.

    Notes

    pearl
    1

    Female patients treated by male surgeons more commonly experience post-operative complications and death than when treated by female surgeons.

    Daniel Jolley  Daniel Jolley
    summary
    1

    What did they do?

    Fascinating big-data study covering 12 years of the 20-most-common surgical procedures in Ontario, Canada. Wallis, Jerath & co. investigated how patient-surgeon sex discordance correlated to a composite for adverse postoperative outcomes. (A deeper investigation of the related Wallis 2017 study).

    And they found?

    While ~15% of all patients experienced an adverse post-operative outcome, female patients treated by a male surgeon experienced significantly higher odds of a composite of adverse events (OR 1.15 [1.10-1.20]), 30-day complications (OR 1.16 [1.11-1.22]), readmissions (OR 1.11 [1.04-1.19]), and death (OR 1.32 [1.14-1.54]) compared to when treated by female surgeons.

    Yet male patients treated by female surgeons experienced either lower odds (death 0.87 [0.78-0.97]) or statistically-similar odds of complications (composite end-point, readmission or post-op complications).

    The hot-take

    Women once again receive the metaphorical short-end of the medical-stick. Whether societal or elsewhere in the health industry value-chain, long established gender inequity reveals itself in worse surgical outcomes for female patients.

    Hang on a sec…

    But this cannot just be written off as a consequence of existing social gender inequity, but rather a disquieting causal loop between this as a cause and the result then perpetuating further inequity.

    If some part of a surgeon’s ’professional success’ is wrapped-up in the ability to achieve positive outcomes for patients while minimising the adverse, then male surgeons are failing their female patients when compared to either female surgeons, or to the care they provide their male patients.

    And yet the same discordance cost is not true for female surgeons.

    The take-away

    If you are a male surgeon at all interested in successful patient outcomes (surely that’s every surgeon?), then this should make you very, very uncomfortable. At the very least it should make male surgeons stop and consider whether their female colleagues conduct any aspects of their practice differently – particularly when treating female patients.

    Daniel Jolley  Daniel Jolley
     
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