Death rates after major surgery are similar regardless of whether a male or female surgeon operates on a male or female patient, a large US study published in The British Medical Journal (BMJ) has found. Differences seen in the study were small and not clinically meaningful, and the researchers say their findings should help improve processes and patterns of care for all patients.
“It is important for patients to know that the quality of surgical care provided by female surgeons in the USA is equivalent to or, in some cases, slightly better than that provided by male surgeons,” said senior author Yusuke Tsugawa (David Geffen School of Medicine at University of California Los Angeles [UCLA], Los Angeles, USA). “Given that the difference in patient mortality between female and male surgeons was small, when choosing a surgeon, patients should take into account factors beyond the gender of the surgeon.”
Gender concordance between patients and physicians—when the physician and patient are of the same sex—is generally linked to higher quality care processes and improved patient outcomes, owing to more effective communication, reduced (implicit and explicit) sex and gender bias, and better rapport.
However, as stated in a The BMJ press release, evidence about the effect of patient and surgeon gender concordance on outcomes in patients undergoing a surgical procedure is “limited”. To address this, a team of researchers set out to determine whether patient-surgeon gender concordance is associated with death after surgery in the USA.
Their theory was that patients treated by surgeons of the same gender would have a lower postoperative death rate than patients treated by gender-discordant surgeons. They analysed data for almost three million Medicare patients aged 65–99 years who underwent one of 14 common major urgent or elective surgeries between 2016 and 2019: abdominal aortic aneurysm repair, appendectomy, cholecystectomy, colectomy, coronary artery bypass surgery, knee replacement, hip replacement, hysterectomy, laminectomy or spinal fusion, liver resection, lung resection, prostatectomy, radical cystectomy, and thyroidectomy.
In this observational study, post-surgery mortality was defined as death within 30 days of the operation. Adjustments were made for patient characteristics, such as age, race and underlying conditions; surgeon characteristics, such as age, years in practice and number of operations performed; and hospital fixed effects (effectively comparing patients within the same hospital).
Of 2,902,756 patients who had surgery, 1,287,845 (44%) had operations done by surgeons of the same gender (1,201,712 male patient/surgeon [41%] and 86,133 female patient/surgeon [3%]), and 1,614,911 (56%) were by surgeons of different gender (52,944 male patient/female surgeon [1.8%] and 1,561,967 female patient/male surgeon [54%]).
For urgent and elective procedures combined, the adjusted death rate 30 days after surgery was 2% for male patients treated by male surgeons, 1.7% for male patients treated by female surgeons, 1.5% for female patients treated by male surgeons, and 1.3% for female patients treated by female surgeons. And, for elective procedures, female surgeons had slightly lower patient death rates (0.5%) than male surgeons (0.8%), whereas no difference in patient mortality was seen for urgent surgeries.
Several mechanisms could explain this small effect for elective procedures, the authors state. For example, female surgeons may abide by clinical guidelines more than male surgeons, or might have better communication and increased attention to postoperative care than male surgeons, which could affect patient death rates. Furthermore, as elective surgeries allow patients to choose their own surgeon, they are more prone to influence from other factors compared with urgent procedures where patients are assigned to on-call surgeons, they add.
The authors note that this was an observational study, and therefore cannot be used to establish cause—also stressing that other, unmeasured social and cultural factors may have influenced their results. In addition, they say their findings may not apply to younger populations, patients who receive procedures that are less common, or patients in countries outside of the USA.
Nevertheless, they believe that understanding the underlying mechanisms of the phenomena observed in this study “allows the opportunity to improve processes and patterns of care for all patients”.
“Ongoing qualitative and quantitative research will better delineate how surgeon and patient gender, along with race and other aspects of shared identity, affect quality of care and outcomes after surgery,” the authors add.
