Women treated by male surgeons may drive the association

Does sex matter when it comes to surgery outcomes? A retrospective study has found that patients fared worse when surgeons and patients were of the opposite sex.

A composite outcome of death, readmission, or significant complications within 30 days was tied to patient-surgeon sex discordance (adjusted OR 1.07, 95% CI 1.04-1.09), reported Christopher Wallis, MD, PhD, of University of Toronto in Canada, and co-authors.

Sex discordance led to worse outcomes for female patients (adjusted OR 1.11, 95% CI 1.06-1.16), but better outcomes for male patients (adjusted OR 0.96, 95% CI 0.93-0.99; P for interaction = 0.004), they reported in JAMA Surgery.

Of the three components in the composite outcome, death (adjusted OR 1.07, 95% CI 1.02-1.13) and complications (adjusted OR 1.09, 95% CI 1.07-1.11) were independently associated with sex discordance, but readmission was not (adjusted OR 1.02, 95% CI 0.98-1.07).

“In this population-based cohort, we found consistent evidence that adverse postoperative outcomes, defined as the composite of death, readmission, or complications in the 30 days following surgery, were significantly more common when there was a discordance between surgeon and patient sex after accounting for both patient and surgeon sex as well as the specific procedure being performed and other procedure-, patient-, surgeon-, and hospital-level factors, although the absolute magnitude of this association was relatively small,” Wallis and co-authors wrote.

“Further analyses support that worse outcomes among female patients treated by male surgeons drives the observed association of sex discordance,” they added.

The group studied 1,320,108 adults who had one of 21 common surgical procedures from January 2007 through December 2019 while covered under the Ontario Health Insurance Plan in Canada. They tracked surgeon-patient sex concordance as a binary (discordant vs concordant) and four-level categorical variable (possible male-female combinations).

Sex-specific procedures were excluded from the analysis. Procedures included coronary artery bypass grafting, femoral-popliteal bypass, abdominal aortic aneurysm repair, appendectomy, cholecystectomy, gastric bypass, colon resection, liver resection, spinal surgery (decompression and arthrodesis), craniotomy, knee replacement, hip replacement, open repair of the femoral neck, total thyroidectomy, neck dissection, lung resection, radical cystectomy, and carpal tunnel release. Procedures were performed across a variety of subspecialties and included open and laparoscopic approaches when appropriate.

One or more adverse postoperative event occurred in 14.9% of surgeries, with death in 1.7%, readmission in 6.7%, and 8.7% with significant complications.

Overall, 602,560 cases were sex concordant (male surgeon with male patient, 509,634; female surgeon with female patient, 92,926). A total of 717,548 cases were sex discordant (male surgeon with female patient, 667,279; female surgeon with male patient, 50,269).

Sex discordance was associated with longer length of stay (adjusted relative rate 1.11, 95% CI 1.06-1.15).

“There was significant heterogeneity between surgical specialties; however, the effect estimate indicated that sex discordance was associated with higher event rates for all specialties,” the authors wrote.

“There was further significant heterogeneity according to patient age, with an increasing magnitude of the association of sex discordance with increasing patient age,” they added. “While there was no significant heterogeneity of effect between elective and emergent surgery, the effect estimate was null for those undergoing emergent surgery.”

In an accompanying editorial, Andrea Riner, MD, MPH, and Amalia Cochran, MD, both of the University of Florida in Gainesville wrote, “The association between surgeon-patient sex discordance and outcomes sounds the alarm for urgent action. Although the underlying reasons for this disparity are not fully understood, which warrants further investigation, action should be taken immediately.”

“Surgeons likely believe they provide the same quality of care to patients irrespective of identity,” they added. “However, these data underscore an underappreciated phenomenon and highlight a measurable repercussion of implicit bias.”

They suggested:

  • Efforts to recruit women into surgery should be ramped up, including fostering supportive environments and inclusive culture. “Funneling more women into the pipeline and repairing the leaks that contribute to attrition offer system-wide solutions to the problem,” they wrote.
  • Metrics of surgeon outcomes with regard to patient identity should be developed and incorporated into performance reviews.
  • Training programs to develop skills and improve care and communication with patients of diverse identities are needed.

“In situations of surgeon-patient sex discordance, an additional measure of diligence and sensitivity that exceeds the goal of treating all patients similarly may be indicated,” Riner and Cochran observed.

“While data are lacking, the concerns faced by female patients undergoing surgery may be even greater for gender-nonconforming and transgender patients,” the editorialists added. “We owe it to patients to provide them with the best outcomes, regardless of how their identities may align with ours.”

Prior research suggested the patient-physician relationship is strengthened by a shared identity, based on sex, race, or other shared characteristics. A 2018 study found higher mortality in female heart attack patients treated by male physicians, with similar male and female mortality for those treated by female physicians.

Limitations of the present study include those inherent to observational studies. In addition, sex but not gender was used, and the latter “may more meaningfully affect interpersonal interactions,” the authors noted.

  1. Outcomes were worse when surgeons and patients were of the opposite sex, a retrospective study found.

  2. Sex discordance led to worse outcomes for female patients, but better outcomes for male patients.

Paul Smyth, MD, Contributing Writer, BreakingMED™

Wallis had no disclosures.

Riner reported grants from the National Human Genome Research Institute and the National Cancer Institute. Cochran is a section editor for UpToDate.

Cat ID: 159

Topic ID: 97,159,504,728,791,730,192,925,159