"Surgery in the UK remains a hugely male-dominated area of medicine"

January 26, 2022 7:41 PM

In a study reminiscent of last year's finding that Black babies are more likely to survive if they have Black doctors (study), a new study has found that women are 32% more likely to die after operation by male surgeon (study).

The studies found that men's outcomes are not affected by the sex of their surgeon, and white babies' outcomes are not affected by the race of their doctor. Both studies used sample sizes of greater than 1 million.

posted by clawsoon (30 comments total)

The BBC Radio 4/World Service programme More or Less discussed this last week: Are female patients more likely to die if the surgeon is male?

The take away: the effect is real, but small in absolute terms (5/1000 vs. 6.5/1000) — the headline risk difference is relative not absolute. Definitely worth more follow up though as it is in the same direction as so many other healthcare disparities.
posted by Quinbus Flestrin at 9:04 PM on January 26, 2022 [15 favorites]

The most plausible explanation I've seen is that it's not the surgery itself that's the problem, but rather the pre and post-op care. That would match the common observed bias with male doctors and female patients.
posted by Tell Me No Lies at 9:25 PM on January 26, 2022 [6 favorites]

I’ve had surgery seventeen times, and the most recent one was the only time the entire team (surgeon, nurses, and anesthesiologist) were women.
posted by The Underpants Monster at 9:47 PM on January 26, 2022 [8 favorites]

I came to link that More or Less episode too. It's a really enlightening show for anyone who wants to properly understand the statistics which bombard us daily and how badly these numbers are often misunderstood or twisted by the media. It's a British programme, and so draws most of its examples from UK rather than US news, but the lessons it provides apply everywhere.
posted by Paul Slade at 11:53 PM on January 26, 2022 [4 favorites]

Was this the result of a few doctors with a large disparity in outcomes, or a large number of doctors with a small disparity?
posted by clawsoon at 2:05 AM on January 27, 2022 [2 favorites]

Looking at the abstract, I see that the data is actually from Ontario, not the UK.
posted by clawsoon at 2:09 AM on January 27, 2022 [1 favorite]

the effect is real, but small in absolute terms (5/1000 vs. 6.5/1000) — the headline risk difference is relative not absolute.

Which is exactly what "32% more likely" expresses.

I'm going to take a stab here and say that women also have more surgeries per cap than men (outside of military considerations). I'll be happy to be corrected, if I'm wrong.

I'm a bloke who hasn't had surgery (not counting stitches) since I was nine or ten or so, and even I have anecdata of shitful care by male doctors and surgeons of female patients. One instance: my Mum once had a specialist contact her after surgery, to apologise for dismissing her complaints of pain, after the surgeon had said "Oh, shit, that was the worst case of $thing I've ever seen". This dickhead had just been dismissing her pain as whingeing for months. My Mum is the most stoic person I've ever known, and if she admits to pain, it's A BIG THING.
posted by pompomtom at 2:56 AM on January 27, 2022 [14 favorites]

Sci-hub didn't have a copy of the study, but Google Scholar did find this PDF copy.

If I'm doing early morning math correctly, there were 559,903 male patients and 760,205 female patients. I'm having trouble figuring out what the overall increase in complications was, but for general surgery specifically it looks like it was from 98 per 1000 to 113 per 1000 for women with a female vs. male surgeon.

About my earlier question about whether it's a few doctors with a large disparity or a large number of doctors with a small disparity, it looks like the disparity is there in pretty much every subcategory, which seems to suggest that it's a large number of doctors with a small disparity.

They do say that female surgeons on average treated younger patients with less comorbidities, which seems like it would explain why female surgeons had better outcomes overall, but doesn't seem like it would explain the discordant disparities.

Please correct me if I'm wrong on any of this.
posted by clawsoon at 4:24 AM on January 27, 2022 [8 favorites]

I've always operated from the perspective that women and people of color have had to work harder and better their entire lives than white men to gain their professional degrees. Therefore, whether it's medicine or another profession, I choose anyone over a white man. Yes, it's reverse discrimination, but I'd say the history of humankind needs some of that to balance itself out.
posted by arancidamoeba at 4:32 AM on January 27, 2022 [21 favorites]

Please correct me if I'm wrong on any of this.

"Fewer", not "less".

;-)
posted by pompomtom at 5:39 AM on January 27, 2022 [5 favorites]

"Fewer", not "less".

I just doubled-checked the paper and it looks like my actual error was "comorbidities" when it should have been "comorbidity". "Less comorbidity". Which I guess means comorbidity is some kind of mass noun?
posted by clawsoon at 5:48 AM on January 27, 2022 [3 favorites]

I'm not shocked to hear any of this. It figures.
posted by jenfullmoon at 8:10 AM on January 27, 2022

Just a trivia note: When I worked engineering in surgical devices at $BIGCORP, it was often noted that a continuing barrier to women surgeons was just equipment size. One of the best surgeons we worked with needed a step-stool so she could reach the table, because it wouldn't lower enough.

When we brought up resizing our surgical devices to fit smaller hands, it was said "But then we'd need to validate two of them! Hospitals would need to stock two of them! And there aren't enough women surgeons to cover the cost!" This may not seem like much, but using the larger device caused greater exhaustion on smaller hands. Not great for a surgeon.

We never really managed to overcome this kind of circular thinking.
posted by SunSnork at 8:19 AM on January 27, 2022 [35 favorites]

The take away: the effect is real, but small in absolute terms (5/1000 vs. 6.5/1000)

But that "small" effect, multiplied by the total number of operations performed each year by male surgeons on female patients, results in a non-trivial number of excess deaths and complications.

The study included 667,279 operations by male surgeons on female patients over 12 years. That's ~55,600 operations per year. A difference of .0015 still amounts to excess 83 deaths per year, and that's just among those 21 types of procedure in Ontario (population ~14.5 million).

For a sense of scale, a very rough estimate from applying that rate to the United States gives something like 1800 excess deaths per year. Medical sexism killing hundreds of women in the US each year seems pretty significant in absolute terms, to me.

Both of these studies should be profound wake-up calls for the medical profession to figure out and address the root causes of these inequities. A doctor failing to do something that would reduce a patient's risk of death by 23% (or ~48% in the case of the Black infant mortality study!) would normally be a pretty strong malpractice claim. Maybe we can start by docking male surgeons' pay by 23% and using the money to fund remedial training for male surgeons and scholarships for more female surgeons.
posted by jedicus at 8:19 AM on January 27, 2022 [23 favorites]

I wonder what the age distribution of surgeons is as well. I suspect the older end of the population is heavily male and I wonder if both physical age and not having modern training is a contributing factor.
posted by Tell Me No Lies at 8:26 AM on January 27, 2022

No, never mind. That wouldn't explain the gender disparity.
posted by Tell Me No Lies at 8:28 AM on January 27, 2022 [2 favorites]

I wonder what the age distribution of surgeons is as well. I suspect the older end of the population is heavily male and I wonder if both physical age and not having modern training is a contributing factor.

You already followed up your comment, but for clarity, the study did control for that, among other things:

Patient age, sex, geographic location ... , geographically derived socioeconomic status, rurality, and general comorbidity ... were obtained. We also collected data regarding surgeon sex, years in practice, specialty, and surgical volume. Surgical volume was determined for each surgeon and the specific procedure by identifying the number of identical procedures the operating surgeon performed in the previous year, operationalized in quartiles. Hospital institution identifiers were used to account for facility-level variability. ...

We used multivariable generalized estimating equations (GEE) with an independent correlation structure and logit link to estimate the association between patient-surgeon sex concordance and outcomes, accounting for patient-, surgeon- and hospital-level covariates

posted by jedicus at 8:31 AM on January 27, 2022 [4 favorites]

Resident of Ontario here who spent about a decade in the public health industry in one capacity or another. I've worked closely with a few surgeons.

This isn't just of academic interest, or a statistical artifact. This is a real thing that's happening that's costing lives. In my lifetime I've seen doctors do the following : a) insist that a woman who wanted an IUD bring her husband to the appointment and procedure so that he could consent; b) not wash their hands (before or after) or wear gloves while examining a patient's genitals; c) say that children 12 and younger can't remember things, so there's no need to wait for anesthetic before stitching wounds or setting broken bones; d) say that first nations people have a "different culture" around pain or consent, which makes it "easier" to treat them. This isn't ancient history, it's happening now.

There's a huge difference between Canada's reputation (in some circles) and the reality of living here. We've got a lot of work to do and a lot of ground to cover.
posted by LegallyBread at 8:37 AM on January 27, 2022 [21 favorites]

I suspect the older end of the population is heavily male and I wonder if both physical age and not having modern training is a contributing factor.

Oddly enough, the study also found - though it wasn't statistically significant - that the only case in which sex discordance resulted in better outcomes was if the surgeon was older than 60. The adjusted odds ratio was 0.91, with a 95% confidence interval of 0.80-1.02. That could be an entirely random result, but it's interesting that it points in exactly the opposite direction from what you (and I) would expect.
posted by clawsoon at 8:38 AM on January 27, 2022 [2 favorites]

The women in my life have been dealing with a lot of health care issues lately, from major back surgery to arthritis to cancer. It has been shocking how little regard male doctors and surgeons have shown for bedside manner, proper diagnosis of pain causes, or post-op care. On top of the general soft collapse of the medical system due to COVID it's been not great.

My aunt who had back surgery didn't find out the full extent of the work the surgeon did back there until 2 months after surgery. I got the sense a lot of male surgeons are smart sociopaths who get off on the prestige of the work they complete, and care little for the effect on the patient. It's fine if it's necessary work to improve outcomes, but you need to notify the post-care system to the extent of the procedure so that they can administer proper pain meds and other care.

The focus on the death number here belies HUGE numbers of women who didn't die but received substandard care and despite it, managed to survive. Many I'm sure with complications.
posted by JauntyFedora at 10:43 AM on January 27, 2022 [11 favorites]

I interact professionally with many different professions. It's been my experience that surgery is the only profession where it is still acceptable to be a bullying arsehole.

This isn't just my experience, it's a recognised but unsolved problem:
Australia - Bullying and harassment of health workers endangers patient safety
New Zealand - Bullying in the New Zealand senior medical workforce: prevalence, correlates and consequences
UK - Workplace bullying in the UK NHS: a questionnaire and interview study on prevalence, impact and barriers to reporting
Canada - Harassment in the medical profession flagged by doctors

Surgery has a workplace culture problem. This is a problem that kills people. This is a problem that is self-perpetuating - I know smart and kind people who have moved away from careers as clinicians because of this bullying.

Given that, of course these disparities exist and persist. The most useful question to address next is what will it take for the profession to admit to these problems?
posted by happyinmotion at 11:42 AM on January 27, 2022 [7 favorites]

I recently started reading this eye-opening book, Unwell Women: Misdiagnosis and Myth in a Man Made World by Elinor Cleghorn, which traces the history of women's bodies being considered "alien" and "defective" and "weaker" when compared with the standard which is, of course, men's bodies, and how that has affected medical care for women for centuries. I am in the early history stages now--the days of wandering wombs, womb suffocation, and, of course, witches, but I know the book is going to move on to more contemporary case studies. Here's The Guardian review.
posted by ceejaytee at 12:01 PM on January 27, 2022 [7 favorites]

I had interesting surgical experience in the late seventies where the experience was a relatively minor reverse of this issue. I had my appendix out - I'm male and the doctor was male. 3-4 inch incision with 4 stitches. A female classmate of mine had her appendix out the same week. 2 inch incision - 10 stitches. We were roughly the same size and build. I have a scar that looks like a dead worm on my stomach to this day. Her scar was barely visible within a month of the operation. One of the few instances where a woman can benefit from medical sexism I guess.
posted by srboisvert at 1:00 PM on January 27, 2022

This seems like a good thread to plug Maya Dusenbery's Doing Harm. Fascinating and infuriating.
posted by BlueNorther at 1:20 PM on January 27, 2022 [1 favorite]

One of the few instances where a woman can benefit from medical sexism I guess.

The sexism here was designed to benefit both of you, you're supposed to embellish about what the scar was from :). (I jest, I would not want a big stomach scar either)
posted by JauntyFedora at 1:49 PM on January 27, 2022

Metafilter: wandering wombs, womb suffocation, and, of course, witches
posted by The Underpants Monster at 2:36 PM on January 27, 2022 [2 favorites]

There might be possibly another source for this discrepancy: perhaps senior surgeons are more likely to be male and white because of professional gender and racial discrimination. They thus would be assigned the more "difficult" operations, with higher morbidity. This is actually pointed in the article on gender disparities. It might well be that this is the source of bias.
Also one might suggest that the proper title for the articles is "Canadian women are 32% more likely to die after operation by a male surgeon" and "Black babies in the USA are more likely to survive if they have Black doctors - or even "Black babies in the US South..." The studies offer no indication of the effect of gender or racial concordance in other parts of the world. It would be interesting to see if these effects are still discernable in countries such as Russia, say, where there is a longer tradition of somewhat more balanced numbers between male and female doctors and surgeons
posted by talos at 2:38 PM on January 27, 2022 [1 favorite]

talos: They thus would be assigned the more "difficult" operations, with higher morbidity.

The study does mention that explicitly. However, looking at all the ways they sliced up the data on page E6, including by comorbidity, and found that a woman being treated by a man was worse off almost every way they sliced it, it looks like that might not have as much explanatory power as one might think. Presumably worth studying in more detail.
posted by clawsoon at 2:58 PM on January 27, 2022 [3 favorites]

If the excess deaths could be attributed to comorbidities I wonder how many of them resulted from conditions for which women unsuccessfully sought diagnosis or treatment.
posted by Fish, fish, are you doing your duty? at 3:00 PM on January 27, 2022 [7 favorites]

Some ass on Reddit recently said, “If your wife has a headache 17 days in a row, she needs to go to the doctor.”

After I got done laughing, I just wanted to tell him how very few doctors would do anything but get mad at any female patient who dared to waste their time by coming in with only 17 consecutive days of debilitating headache (unless they visibly had brain matter oozing out of their ears). But if you haven’t lived through it you’re not that likely to believe it.
posted by The Underpants Monster at 9:20 PM on January 30, 2022 [3 favorites]