I recently saw a headline from the British Medical Journal that really surprised me: “Death rates after major surgery are similar regardless of whether a male or female surgeon operates on a male or female patient, finds this large US study.”
It surprised me because over the past several years, there have been several studies suggesting that, in fact, women are just better than men at sticking their hands in your guts. It’s a fact of nature that men simply do not possess the biological ability to wield a scalpel. A woman’s place is in the operating theater. If you go to the ER to have a nickel removed from your nostril and a man walks through the door holding tweezers, leave immediately lest you significantly increase your chance of dying in the next 30 days.
Okay, I might be overstating the case a bit. But yes, back in 2017 some researchers examined 104,630 patients having surgery and found that “Fewer patients treated by female surgeons died, were readmitted to hospital, or had complications within 30 days than those treated by male surgeons. Patients treated by female surgeons were less likely to die within 30 days.”
It was a small difference, but statistically significant, meaning that more research needed to be done to see if that is a real phenomenon and then, if so, to figure out why it exists. Follow-up studies have been done, like this paper from 2022 that looked at over 95% of the gastrointestinal surgeries performed in Japan between 2013 and 2017. They actually found no significant difference between male and female surgeons’ patients’ mortality, but that was despite the fact that female surgeons were much more likely than male surgeons to be assigned high risk cases, like those who are malnourished, on long term steroids, or with later stage diseases.
With that in mind, I wondered if the BMJ headline of “Death rates after major surgery are similar regardless of whether a male or female surgeon operates on a male or female patient” might be missing some context, and so I dove in. My first surprise was that this study features many of the same authors as that 2017 paper. My second surprise upon reading the paper is that it actually supported the previous research and found something novel that the BMJ’s headline obscures.
In this sorta sequel to the 2017 paper, Canadian epidemiologist Christopher JD Wallis and his team examined every single US Medicare patient “aged 65-99 years who had one of 14 major elective or non-elective surgeries in 2016-19,” giving them nearly 3 million data points. While they did look at male versus female surgeons and patient mortality, they were specifically challenging the hypothesis that male patients did better with male surgeons and female patients with female surgeons, rather than the patient being a different gender than the surgeon.
Because I was kidding about the idea that men just aren’t naturally, biologically good at surgery. There is no surgical skill gene, as far as I know. It’s likely that if female surgeons have better outcomes than male surgeons, there’s some sociocultural reason (or ten) behind it. And one way to start to explore what those reasons are is to look at the outcome of what’s called “gender concordance” in surgeries, meaning the patient and surgeon share the same gender.
Previous research has suggested patients have better outcomes with doctors of their same gender, possibly due to improved communication between the two, allowing the patient to feel more comfortable connecting with their doctor, which leads to better follow-up care. So this paper explored whether that was true of surgery as well.
And surprise! It wasn’t! This is the rare example of a paper that failed to find evidence for the hypothesis but it still got published, which is refreshing, honestly. The researchers found no significant difference in post-operative mortality rates between all four variables: male physicians with male patients, male physicians with female patients, female physicians with female patients, and female physicians with male patients.
That’s what the BMJ headline meant: not that there’s no difference between the success of male versus female patients, but that this specific study found no difference between patients who did or did not share a gender with their surgeon.
But wait! If there was no statistically significant difference between those four groups, doesn’t that mean that there’s no difference between female and male surgeons at all? Not exactly.
First of all, this study found the same thing the Japanese study found last year: “compared with male surgeons, female surgeons were more likely to treat patients who had conditions that were predictive of higher risk of death.” So already, the fact that they have statistically equal mortality rates means that the female surgeons are probably doing better.
And by the way, I say “statistically equal” but if you’re curious, “The adjusted mortality 30 days after a surgical operation was the lowest for female patients treated by female surgeons (0.4%), followed by female patients treated by male surgeons (0.6%), male patients treated by female surgeons (0.6%), and the worst for male patients treated by male surgeons (1.0%).”
But the researchers decided to also split the data into elective versus non-elective surgeries to see if that changed things for their concordance hypothesis. They found that there was still no significant difference between the groups when looking only at elective surgeries, but there WAS a small but statistically significant difference between female surgeons treating either sex and male surgeons treating either sex: just like in the Canadian study, female surgeons had lower postoperative mortality rates than male surgeons.
Why is that? Tough to say. Patients are more likely to be able to choose their surgeon for elective surgeries, so that might have something to do with it. Or there could be a confounding factor – some third variable that wasn’t measured that is actually responsible for these results. So the authors say they can’t speak to causality, but “If our findings were causal, these results suggest that increasing gender diversity within the surgeon workforce has the potential to improve the quality of surgical care and patient outcomes. Given many challenges female surgeons face, such as the potential effect of marriage, childbearing, and gender discrimination on their careers as surgeons, creating a supportive work and training environment for female surgeons has the potential to promote the gender diversity of the surgeon workforce.”
A systematic review from 2021 supports this, as the authors write that surgery is “the most women-unfriendly specialty,” and female surgeons face a higher attrition rate and report mind boggling amounts of discrimination in the workplace. It makes me wonder if maybe female surgeons are better simply because most women are bullied out of their careers, and the ones who are left possess an otherworldly passion, and maybe an enhanced ability to put up with shit in order to do their jobs. And it also makes me wonder how much better they’d be able to do their jobs if they weren’t putting up with so much shit. That review found “females were given less operative autonomy by attendings, impacting their confidence, training quality, and performance.” They’re doing better than the men even with all that!
And perhaps most sadly, the review found a “survivorship bias, where some senior female surgeons who overcame the odds to succeed in a male-dominated culture expected their subordinates to do the same. In such cases, they tended to focus on personal resolve as the crucial success factor, diverting attention from problematic gender barriers.”
The good news is that they found that certain media advocacy efforts have been successful at helping female surgeons feel more accepted and connected to one another, and are making workplaces and organizations take steps to create more inclusive environments.
The takeaway here is that yes, female surgeons do have slightly better outcomes than male surgeons but you probably shouldn’t balk if you go in for some stitches and are greeted with a man. That would be discrimination, and that’s probably how we got here in the first place.