Early this year, a Canadian study published in JAMA Surgery confirmed what many patients, especially female patients, have long suspected: The sex of your surgeon absolutely matters when it comes to your outcome in the operating room. Female physicians got better results. But it turns out that the sex of the patient matters in the OR, as welland can even mean the difference between life and death.Angela Jerath, an associate professor of anesthesiology at the University of Toronto, and her colleague Christopher Wallis, an assistant professor of surgery in the department of urology, canvassed the records of more than 1.3 million men and women, operated on by nearly 3,000 surgeons in Ontario over 12 years. They controlled for as many factors as possible: the age, income, and health status of the patients; the age and experience level of the surgeons; whether the surgery was performed in a small community hospital or a major medical centre. Overall, Jerath and Wallis discovered, more than 17 percent of patients suffered adverse effects within 30 days of the procedure8.7 percent of them had complications, 6.7 percent were readmitted to hospital, 1.7 percent died. Not the best.But when they broke down those results by sex, something more troubling emerged. We found that female patients treated by male surgeons had 15 percent greater odds of adverse outcomes than female patients treated by female surgeons, Jerath says. Worse still: Women operated on by a male surgeon were 32 percent more likely to die.Here, Jerath unpacks those astonishing findings and explains how on earth we can fill the gap in care for female patients.(Related: Womens Health Collective Canada Is Addressing the Gap in Womens Health)
Why did you want to explore this area in the first place?
Chris Wallis had done some earlier work that looked at differences in outcomes between male and female surgeons, using a similar dataset from Ontario health care. That paper signalled that female surgeons across different specialities are having better outcomes than their male counterparts. And we werent really sure why. To be honest, were still trying to work out why. But one of the areas of interest was whether the interaction between the sex of the physician and the sex of the patient matters.
How did you go about measuring whether it matters?
We have the luxury of lots of health care databases in Ontario, and theyre completely anonymized. We looked at the pairings between the sex of the patient and the physicianso youve got four combinationsand we looked at its impact on death, readmission to hospital, or complications after surgery within 30 days. This was on around 21 surgical procedural groups, from things that are really complex, like cardiac bypass surgeries, to common bread-and-butter stuff, like having your hip or knee replaced. We were able to adjust for a lot of things that affect outcomes, like the age of the patient or the experience of the surgeon. We jam-packed those things into the model and came out with the numbers that you see.
Lets talk about those numbers.
Theyre pretty scary.
What did you think when you first saw them?
I was personally taken aback. We had a lot of internal discussions and went through the data again. Chris had done that earlier work, so we knew there was a signal here, but we just didnt know how big the signal was going to be. Its important to understand what those numbers might mean. Theyre what we call relative numbers. Women having surgery with a male surgeon, relative to a female surgeon, had a 32 percent increased risk for death. That means if your risk for death coming in for surgery is, lets say, one percent, then its 32 percent of that one percentso the combined outcome is about 1.3 percent. Thats how to mentally compute what youre seeing.
But should there be a difference at all?
No. And that needs a deep dive. We saw this difference across a lot of surgeries, and there were 1.3 million procedures in our database. Given that volume, we dont sense that this is some technical thing in the operating room. The operating room is just one part of your surgical experience, which starts as soon as you step into the hospital and meet the team.
What do you think is going on here?
There may be differences around communication, understanding what a patient wants; perhaps theres a difference in decision-making. Very few people die in the operating room. Most things happen after surgery, and picking up on those complications early can be life-saving. Perhaps men and women physicians are communicating with their teams differently. Perhaps theyre listening to patients differently. There are a lot of subtleties, which I will say dont get taught at medical school, that might feed into some of those adverse outcomes. There are likely to be differences in style that we can all learn from.
Better communicators, better listenersnot to truck in gigantic generalizations, but that does sound like women to me. Has that been your experience working as an anesthesiologist in the operating room?
Id say I work with great people, technically and clinically, everywhere. I find women will communicate a bit more. And if Im concerned about something and we need to pause or think or go faster or whatever, I find they listen. It is a bit of a generalization. There are some men who do that really well. There are probably some women who do that really badly. But Im starting to see more women surgeonsmore women in leadership generallyfrom when I was a medical student 20 years ago. To get where they are, women often have to do much more; theyve got to tap into tons of skills, go the umpteenth mile.
And have you noticed differences in female patients, in terms of how they might discuss their symptomsor how they might be received by surgeons of the opposite sex?
I find women will ask more questions, but you know, how you ask your questions often dictates whats underneath. Maybe youre a bit nervous, or you need more reassurance about why something is important, or you may not want to do a procedure. A lot of conversation often means something else. How we perceive that information, as physicians, is so important.
How do we begin to fill this gap?
Weve highlighted an issue, and now we need different researchers to come in. Understanding more about risk might be important. Are there patients were considering operating on who can get through the operation, but perhaps run into issues more frequently after surgery? And then we need researchers with an anthropological or psychology background to really dive into differences in communication style.
What has the response to this paper been like? I imagine some people in the medical community might be a bitresistant to the findings.
Its been a mixed bag. A lot of women feel vindicated and that their work has been recognized. There have been some male surgeons who have come up to me and said, This is fantastic; youve highlighted an important area. Theres a group in the middle who are quiet. And then there are people who are angry. Weve had those emails, those messages on Twitter, where people feel their whole practice has been affected and are taking it very personally. Male surgeons in particular have taken it very personally.
Should they?
Our response has been that this is a very macro-level study. Thats what big data is really good at doingit highlights something. But its generalistic. It can never make an inference on your individual practice.
Since were on a macro level, I imagine its a long process to turn around these disparities in care.
Probably. If there was, lets say, a lot of funding, it would be easier to carve out lots of topics to start examining which would help accelerate us forward. But a subject like this, which is more embedded in the health equity and disparity space, is becoming more of a core subject. People are understanding that this isnt just dinner-party conversation. Theres real science to behold here.Next: How Heart Disease Affects Women Differently Than Men
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