Female patients are more likely to experience adverse outcomes following common surgical procedures when treated by a male rather than a female surgeon, according to a new analysis of over 1.3 million surgery patients. The study found no difference in adverse outcomes in male patients treated by surgeons of either sex.
While the effect of patient and provider sex discordance (female patient/male physician or male patient/female physician) on care has been explored before, “to the best of our knowledge, this is the first study to assess this in patients undergoing surgery,” Christopher Wallis, MD, PhD, an assistant professor in the Division of Urology at the University of Toronto, Canada, told Medscape Medical News in an email. The study was published online December 8 in JAMA Surgery.
Past studies in primary care settings have found that sex discordance between a physician and patient can result in “worse rapport, lower certainty of diagnosis, lower likelihood of assessing patient’s conditions as being of high severity, concerns of a hidden agenda, and disagreements regarding advice provided,” the authors write in the paper. Gender discordance has also been shown to negatively affect cancer screening rates and survival after heart attack. Given these past findings, Wallis and colleagues postulated that gender match between patients and surgeons could affect postoperative outcomes.
To find out, researchers analyzed data from over 1,320,100 patients undergoing one of 21 common elective and emergent surgical procedures in Ontario, Canada, from January 1, 2007, through December 31, 2019. Procedures were performed across the following specialties: cardiothoracic surgery, general surgery, neurosurgery, orthopedic surgery, otolaryngology, plastic surgery, thoracic surgery, urology, and vascular surgery. The investigators compared adverse postoperative outcomes — death, readmission, or complications within 30 days after surgery — in patients of both sexes when treated by male or female surgeons.
The study included 2937 surgeons, and nearly 46% of patients included in the study were the same sex as their surgeon. Of the remaining 717,548 sex-discordant pairings, 93% were female patients with male surgeons, and 7% were male patients with female surgeons.
Among all patients, 14.9% experienced at least one adverse outcome. The researchers found that sex discordance between patient and surgeon was associated with higher odds of complications (adjusted odds ratio [aOR], 1.09; 95% CI, 1.07 – 1.11) and death (aOR, 1.07; 95% CI, 1.02 – 1.13). There was no statistically significant relationship between sex discordance and readmission in the study.
Using multivariable modeling, the researchers then teased out how patient sex affected this association. They found that female patients treated by male surgeons, compared to those treated by female surgeons, were more likely to have worse outcomes (aOR, 1.15; 95% CI, 1.10 – 1.20); however, there was no difference in outcomes in male patients treated by female surgeons compared with those with male surgeons (aOR, 0.99; 95% CI, 0.95 – 1.03).
While the study did not look at the underlying reasons for this disparity, communication differences between surgeons and patients could be one factor, Wallis noted. “Prior research has suggested differences in communication style between male and female physicians. Further, there is evidence that female physicians, including surgeons, spend more time with patients,” he wrote in an email. “This, coupled with evidence that female patients may have disparities in the management of their pain, suggest that communication differences may underpin the observed disparity.”
The finding “sounds the alarm for urgent action,” write Andrea Riner, MD, MPH, and Amalia Cochran, MD, both from the Department of Surgery at the University of Florida College of Medicine in Gainesville, in an accompanying commentary. While recruiting more women into surgical specialties is one way to address this disparity, both Riner and Cochran note the importance of identifying unconscious biases in patient care. “Surgeons likely believe they provide the same quality of care to patients irrespective of identity,” they write. “However, these data underscore an underappreciated phenomenon and highlight a measurable repercussion of implicit bias.”
Training programs that work with surgeons to improve communication and care with diverse patients may help counter these biases, they suggest, and incorporating patient identity in surgical outcome metrics could help identify biases. “Female patients with surgical disease should not be disadvantaged because there simply are not enough female surgeons or surgeons who are competent in the care of female patients,” they note. “We owe it to patients to provide them with the best outcomes, regardless of how their identities may align with ours.”
Riner reports grants from the National Human Genome Research Institute and the National Cancer Institute. Cochran is a section editor for UpToDate. Christopher Wallis reports no relevant financial relationships.
JAMA Surg. Published online December 8, 2021.