Do women make safer surgeons?

Should you put your life in her hands? Erin Dean explores why female surgeons may be safer surgeons than their male counterparts.

Women have always been underrepresented in surgery and for those who are there, it is often not an easy journey. Shocking research showing that women are disproportionately affected by high rates of sexual harassment and misconduct in surgery rocked the profession over the past year, and the British Medical Association has highlighted that almost all women doctors experience sexism. Nevertheless, research has also revealed that along with all these challenges, there could be another crucial difference for female surgeons: they have better outcomes than their male counterparts. Two large studies published in the JAMA Surgery journal in August 2023 suggesting that women may be safer surgeons. 3,4 Scarlett McNally, a consultant orthopaedic surgeon at East Sussex Healthcare NHS Trust and president of the Medical Women’s Federation, says that these results have “hopefully, finally, completely stopped the myth that women aren’t good enough”.

The first study looked at the records of almost 1.2 million patients in Canada between 2007 and 2019.It found that those treated by a female surgeon were less likely to experience death, hospital readmission or major medical complications at 90 days or 12 months after surgery. These findings were maintained when accounting for patient, procedure, surgeon, anaesthetist and hospital characteristics. The cohort study considered patients undergoing 1 of 25 common procedures, and noted 1-year mortality rates of 2.4% for men and 1.6% for women. There was a complication rate of 13.9% among patients treated by male surgeons, which compared with 12.5% in patients treated by female surgeons.

A second study, which looked at 150,000 patients who underwent cholecystectomy in Sweden, had similar results. Patients treated by female surgeons had fewer complications and shorter hospital stays than those treated by male surgeons.

The findings confirmed those of other studies demonstrating that women have the same or better outcomes than men even though they are working in a profession rife with sex inequality. A cohort study published in the British Medical Journal in 2022 found no differences in rates of patient death or complications between male and female surgeons in Japan despite the fact that female surgeons were more likely than male surgeons to be assigned high-risk patients.

So what could be making the difference between men and women in the specialty? While both sexes will have been through long and tough training programmes to acquire the high levels of skill necessary for surgery, the women who get through surgical training have generally had to overcome many obstacles, according to senior surgeons who spoke to the Bulletin.

Women continue to be underrepresented in the surgical workforce, with a third (35%) of trainees being female and the proportion of consultants who are female increasing from 9% in 2012 to 14% in 2020. In comparison, over half (57%) of the broader population of medical trainees are female and the proportion of medical consultants who are female increased from 31% in 2013 to 37% in 2020.

“It’s very clear that the women who’ve got through the extraordinarily complex, difficult hurdles to become surgeons are actually the best of the best. No one average would apply,” says Professor McNally. She feels that the differences between male and female surgeons could be partly attributed to unconscious bias from patients, who may find it easier to open up to women and have an honest, open discussion about what may work best for them. This could contribute to ensuring that the right patients are selected for surgery.

Knowing when not to operate is a critical skill for surgeons. Research from the Centre for Perioperative Care, where Professor McNally is deputy director, has shown that 14% of patients expressed regret after going through surgery. “For some patients, operating is not the right way forwards,” she explains.

“The findings confirmed those of other studies demonstrating that women have the same or better outcomes than men even though they are working in a profession rife with sex inequality.”

Complications can be reduced by 50% if patients prepare well for the operation, for example, if they lose some weight or stop smoking, says Professor McNally. “If you’ve got a surgeon who has built a whole team that supports the patient to get through surgery, then you’re reducing your complications because somebody remembered to suggest to the patient to stop smoking and gave them the right information leaflet,” she adds. “So while it is difficult to generalize, and I know great male surgeons and scary female surgeons, I do know lots of women surgeons who have a great team around them.”

Researchers from the Canadian study suggested that for good long-term outcomes, more is needed than just good technical skills. This reinforces Professor McNally’s point about selecting the right people for surgery. The Canadian authors note that previous research in gastric bypass patients has indicated that surgeons who were peer-reviewed to have high levels of technical skill did not achieve better patient weight loss or resolution of medical comorbidities at one year after surgery than surgeons who were judged to be less proficient. Other factors, particularly choosing appropriate patients for surgery, are likely to play an important role in long-term outcomes.

“Only a third of patients in the Swedish study had a female surgeon, as did just over a tenth in the Canadian study, consistent with the underrepresentation of women in surgery we see in the UK.”

Carrie Newlands, a consultant oral and maxillofacial surgeon at the Royal Surrey NHS Foundation Trust and co-lead of the Working Party on Sexual Misconduct in Surgery, says that surgeons should constantly be reflecting and self-auditing their work and their complications. Professor Newlands adds: “There is the old adage that if you don’t know how well you’re doing what you’re doing, you shouldn’t be doing it.”

“Auditing your own outcomes is a vital part of being a good surgeon and also puts your patients at the heart of what you do, but as a profession, we are still not very good at it. Only a third of patients in the Swedish study had a female surgeon, as did just over a tenth in the Canadian study, consistent with the underrepresentation of women in surgery we see in the UK. It would be interesting to see how the results of these women compared with the cohort of male surgeons with the best outcomes.

“Women surgeons are trying to keep their head above water in a tricky sea. Are the ones who have survived their training (which we know can be hostile) more likely to be the type of people who want to know how they are doing so they can do it better?”

Researchers in the Swedish study found that female surgeons operated less quickly and converted to open surgery less frequently than their male counterparts. “As a patient, I certainly don’t care how fast something is done. I want it to be done so that I get the purpose achieved safely and can recover without complications,” says Professor Newlands. “If it takes a very long time to do an operation, then that’s not good for the patient either so there really is a sweet spot in terms of the right length of time for an operation. But speed should not trump outcomes and that may be something that surgeons who take pride in their speed should reflect on.”

Peter Brennan, a consultant oral and maxillofacial surgeon at Portsmouth Hospitals University NHS Trust who researches extensively on the impact of human factors on surgery, says that evidence of sex differences in communication can be seen in the MRCS examination. “Women perform much better on communication skills in surgery exams than men whereas men seem to perform better on basic science, such as anatomy and pathology,” he explains. This communication benefit could affect care in two important ways: when speaking to patients and the culture within a team. “Improved communication could mean better understanding of patients, their problems and selecting the right operation,” says Professor Brennan. “Then from a human factors point of view, women are probably better communicators within the team. They are possibly more likely to be more approachable so that people can speak up and challenge them if they have concerns or if they’re worried about patient safety. This can foster the open culture that can improve safety. Too often these barriers still exist where people can’t speak up.”

When the two JAMA Surgery papers were published in August 2023, there was interest from the public, the media, and surgeons. For surgeons who spoke to the Bulletin about the results from the new JAMA Surgery studies, they were not a surprise. However, they are a valuable learning opportunity for the whole profession to find out more about what could be learnt from female surgeons to improve the safety of patients.

Professor McNally points out that the underrepresentation of women in the profession means that patients are losing out. “We must fix surgical training pathways to remove unnecessary barriers, especially for women surgeons and those who are parents, such as long commutes, excessive administrative duties, and sexist expectations.”

As for Professor Newlands, the findings do bolster some decisions she has made. “I don’t think I was surprised at all by the research,” she says. “And that fits with my recent decisions. I had major surgery not long ago and I chose to be operated on by two amazing women.”

References

1. 1. Begeny CT, Arshad H, Cuming T et al. Sexual harassment, sexual assault and rape by colleagues in the surgical workforce, and how women and men are living different realities: observational study using NHS population-derived weights. Br J Surg 2023; 110: 1,518–1,526.
2. 2. British Medical Association. Sexism in Medicine. London: BMA; 2021.
3. 3. Wallis CJ, Jerath A, Aminoltejari K et al. Surgeon sex and long-term postoperative outcomes among patients undergoing common surgeries. JAMA Surg 2023 Aug 30. [Epub ahead of print.]
4. 4. Blohm M, Sandblom G, Enochsson L, Österberg J. Differences in cholecystectomy outcomes and operating time between male and female surgeons in Sweden. JAMA Surg 2023 Aug 30. [Epub ahead of print.]
5. 5. Okoshi K, Endo H, Nomura S et al. Comparison of short term surgical outcomes of male and female gastrointestinal surgeons in Japan: retrospective cohort study BMJ 2022; 378: e070568.
6. 6.Royal College of Surgeons of England. The Royal College – Our Professional Home. London: RCS England; 2021.
7. 7. Centre for Perioperative Care. Perioperative care: the key to reducing waiting lists. https://cpoc.org.uk/sites/cpoc/files/documents/2023-09/CPOC_ReduceWaitingListsv2.pdf (cited October 2023).