A very interesting study in JAMA Surgery from Wallis et al. received a lot of press coverage. The research team showed that female patients treated by male surgeons not only more commonly experienced post-operative complications, but also suffered a higher mortality, than when treated by female surgeons.
What did they do?
This big-data study covered 12 years of the 20-most-common surgical procedures performed in Ontario, Canada. Wallis and team investigated how patient-surgeon sex discordance correlated to a composite for adverse postoperative outcomes. (A deeper investigation of the earlier 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).
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.
If you are a male surgeon 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.
The negative consequences of patient-physician sex-discordance on outcomes has been observed before, notably Greenwood, Carnahah & Laura Huang found in 2018 that female heart-attack patients were less likely to survive when treated by a male physician than a female physician. Offering a causal glimpse, they also found that this mortality burden lessened when care either occurred in EDs with more female physicians, or from male physicians with more experience treating female patients.
Sun, et al’s 2021 article explored the triad of gender discordance between surgeon, anaesthesiologist and patient for cardiac surgery. Although less conclusive than Wallis’ work, they did show that care from male surgeons and anaesthesiologists (together or alone!) was associated with longer lengths of stay.
Certainly there is a lot of potential for confounders among these studies, although through subgroup analysis and cohort matching, the association between gender-discordance and outcome is arguably robust.
Researching essential (kinda-) immutable characteristics of doctors and how they impact patient care is not new. Tsugawa & Newhouse, et al. (2017) showed that patients treated by older physicians suffered a higher 30-day mortality. Interestingly the difference disappeared for high-volume physicians, suggesting a very believable link between clinical volume and quality maintenance.
More recently, and this time reassuring for old male surgeons (😉), Satkunasivam, et al. (2020) found in a retrospective cohort study of 1.1 million Canadian patients that increasing surgeon age was almost linearly associated with decreases in death, readmission & complications.
Clearly there are some foundational contributors to medical care that we need to understand better. These outcome disparities are not just a failing for the impacted patient groups, but rather a deeper and more concerning failure for our wider practice of medicine.
- Referenced articles can be found in the metajournal knowledge collection, Effect of doctor gender & age on patient outcomes.