— Fewer complications and lower likelihood of adverse postoperative outcomes with women surgeons
by Rachael Robertson, Enterprise & Investigative Writer, MedPage Today August 31, 2023
Patients treated by women surgeons had better outcomes, according to two population-based cohort studies from Canada and Sweden, both of which were published in JAMA Surgery.
The retrospective Canadian studyopens in a new tab or window found that, compared with male surgeons, patients treated by female surgeons had a lower risk-adjusted likelihood of adverse postoperative outcomes at 90 days (13.9% vs 12.5%; adjusted OR 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), reported Christopher Wallis, MD, PhD, of the University of Toronto, and co-authors.
Findings were similar 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).
Most research in surgery looks at short-term outcomes, Wallis told MedPage Today. However, his team wanted to get a better sense of longer recovery trajectories.
“I think the overall takeaway here is that these long-term data parallel the short-term data,” he said. “So we’re actually seeing the effects we observed earlier in terms of short-term differences and short-term outcomes that recapitulated in the longer term.”
“Our goal is not to blame,” he added. “Our goal is to really understand surgical care delivery, so that we can improve care for all patients who are treated by all physicians.”
“The first obvious statement to make is that we can’t just switch and have all surgery performed in the U.S. or Canada tomorrow be done by female surgeons. We just don’t have the workforce to do that. And so the real question is why?” he said, adding that differences are not inherent to a physician’s gender, but rather connected to how they practice.
The findings of the Swedish studyopens in a new tab or window showed that patients treated by female surgeons have more favorable outcomes compared with those treated by male surgeons when looking specifically at cholecystectomies, according to My Blohm, MD, of the Karolinska Institutet in Stockholm, and co-authors.
Patients treated by male surgeons had more surgical complications (OR 1.29, 95% CI 1.19-1.40) and total complications (OR 1.12, 95% CI 1.06-1.19), as well as more bile duct injuries in elective surgery (OR 1.69, 95% CI 1.22-2.34), though no significant difference was observed in acute care operations.
In addition, women surgeons had significantly longer operation times, with a mean difference in operating time for male versus female surgeons of -7.96 minutes for all operations, -6.59 minutes for elective surgery, and -9.27 minutes for acute care surgery (P<0.001 for all).
Because this study focused on one procedure, Blohm said that she and her team could compare specific outcomes and operating times.
Male surgeons also converted to open surgery more often than female surgeons in acute care surgery (OR 1.22, 95% CI 1.04-1.43), and their patients had longer hospital stays (OR 1.21, 95% CI 1.11-1.31).
In an invited commentaryopens in a new tab or window, Martin Almquist, MD, PhD, of Skane University Hospital in Lund, Sweden, noted that the association between female gender and a lower risk of severe complications was both “interesting and important.”
“Evidence has suggested that female surgeons are more likely to use patient-centered decision-making, more willing to collaborate, and more carefully select patients for surgery,” he wrote. “These differences might translate into different outcomes for female and male surgeons. Studying such differences can give important insights into how to avoid adverse outcomes.”
“If future studies prove women have better outcomes than men, it would be interesting to know why,” he concluded. “Perhaps personality traits more common among women contribute to better outcomes? Surely, the idea of the surgeon as the ‘lonesome cowboy’ belongs to an era long gone.”
Blohm told MedPage Today that future research should explore the particular qualities and attitudes surgeons have that may contribute to these differences.
“Even in Sweden, which is considered of the most gender-equal countries in the world, there are still inequities within the surgical specialty,” she said. “Our study might contribute to an increased understanding of gender differences within surgery and we hope that our results will motivate young female physicians and medical students to choose a surgical specialty.”
For the Canadian study, Wallis and colleagues analyzed data from 1,165,711 patients in Ontario, Canada, who underwent one of 25 common elective or emergent surgeries from January 2007 through December 2019. Of these patients, 151,054 were treated by female surgeons and 1,014,657 were treated by male surgeons.
Overall, 14.3% of patients had one or more adverse postoperative outcomes at 90 days, and 25% had one or more adverse postoperative outcomes at 1 year. Among these patients, 2% died within 90 days and 4.3% died within 1 year.
Wallis noted that he and his team are also working on understanding the role of other healthcare team members in the operating room, analyzing the process of pre- and postoperative care, and anthropological research to understand differences in practice.
For the Swedish study, Blohm and team used data from the Swedish Registry of Gallstone Surgery for all patients undergoing a cholecystectomy from January 2006 through December 2019 — 150,509 patients in total. Among those patients, 64.9% underwent elective cholecystectomies and 35.1% had acute care cholecystectomies performed by 2,553 surgeons, of whom 33.3% were women and 67.7% were men. Women surgeons performed fewer cholecystectomies per year and were slightly better represented at universities and private clinics.
The Canadian study was limited by its observational design, which leaves the possibility of residual confounding. Additionally, Wallis and team were unable to assess the complexity of the cases.
In the Swedish study, Blohm and colleagues noted that misclassification of surgeons in the registry may have occurred. Furthermore, because they included both open and laparoscopic procedures in the cohort, this may have affected the results, since open procedures are associated with more complications.
Rachael Robertson is a writer on the MedPage Today enterprise and investigative team, also covering OB/GYN news. Her print, data, and audio stories have appeared in Everyday Health, Gizmodo, the Bronx Times, and multiple podcasts.
The Canadian study was funded by ICES (which is grant funded by the Ontario Ministry of Health and the Ministry of Long-Term Care), as well as the Data Sciences Institute at the University of Toronto.
Wallis had no conflicts of interest. A co-author reported receiving grants from the University of Toronto, Women’s Heart and Brain Award, Heart and Stroke Foundation of Canada, and Health Canada.
The Swedish study was grant funded by the Center for Clinical Research at Uppsala University in Falun, Sweden, as well as the Ruth and Richard Julin Research Foundation.
Blohm had no conflicts of interest. Other co-authors reported being current or former board members for the Swedish Registry of Gallstone Surgery, Endoscopic Retrograde Cholangiopancreatography, and the Swedish Register for (Inguinal) Hernia Surgery.
Almquist reported no conflicts of interest.
Source Reference: opens in a new tab or windowWallis CJD, et al “Surgeon sex and long-term postoperative outcomes among patients undergoing common surgeries” JAMA Surg 2023; DOI: 10.1001/jamasurg.2023.3744.
Source Reference: opens in a new tab or windowBlohm M, et al “Differences in cholecystectomy outcomes and operating time between male and female surgeons in Sweden” JAMA Surg 2023; DOI: 10.1001/jamasurg.2023.3736.
Source Reference: opens in a new tab or windowAlmquist M “Are women better surgeons than men?” JAMA Surg 2023; DOI: 10.1001/jamasurg.2023.3741.