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When a patient of one sex goes under the knife by a surgeon of the opposite sex, outcomes aren't as good -- especially when a male surgeon is involved, according to a population-based study.

Discordance in the sex of surgeon and patient was associated with a relative 7% higher odds (95% CI 1.04-1.09) of death, readmission, or a complication by 30 days after adjustment for the specific procedure and other procedure-, patient-, surgeon-, and hospital-level factors.

The link was significant and of similar magnitude for mortality (adjusted OR [aOR] 1.07, 95% CI 1.02-1.13) and complications (aOR 1.09, 95% CI 1.07-1.11), but not readmission, reported Christopher Wallis, MD, PhD, of the University of Toronto, and colleagues in .

However, only one direction of discordance appeared to be driving the difference (P=0.004 for interaction). Men were at no higher risk from female surgeons than from male surgeons (aOR 0.99, 95% CI 0.95-1.03), but women had a 15% relative higher risk from male than female surgeons (95% CI 1.10-1.20).

"Understanding the causes underlying these observations offers the potential to improve the care for all patients," Wallis and colleagues concluded.

The study "sounds the alarm for urgent action," said Andrea N. Riner, MD, MPH, and Amalia Cochran, MD, both of the University of Florida College of Medicine in Gainesville, in an .

"The elephant in the room is the paucity of female surgeons," they wrote, noting that general surgery has stalled out in the percentage of women entering its residencies to beef up the roughly 22% representation in the field. "It is not just about equity among surgeons; there is a growing body of evidence that this is also good patient care."

No doubt, surgeons believe they provide the same quality of care to patients regardless of their identity, but implicit bias might be at work, Riner and Cochran wrote.

Studies from primary care have suggested similar disadvantages to women being treated by male physicians, Wallis and colleagues pointed out. The worse rapport, lower certainty of diagnosis, lower likelihood of assessing patient's conditions as being of high severity, concerns of a hidden agenda, and disagreements regarding advice provided adversely affect everything from cancer screening rates to mortality after myocardial infarction.

In the surgical setting, potential mechanisms might also include underappreciation of the severity of symptoms in female patients and incomplete postoperative examinations in sensitive situations that together "may contribute to a failure to rescue when patients have minor deviations from expected postoperative pathways" that then cascade to higher rates of serious adverse postoperative outcomes, the researchers added.

Riner and Cochran had some suggestions to address the problem. "Metrics of surgeon outcomes with regard to patient identity should be developed and incorporated into performance reviews. Training programs that are focused on cultural dexterity are needed to develop skills and improve care and communication with patients of diverse identities. 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."

The retrospective study included all 1.3 million adults treated by 2,937 surgeons for 21 common elective or emergent surgical procedures across Ontario, Canada, from 2007 to 2019. Among them, 667,279 female patients had a male surgeon, while 50,269 males were operated on by a female surgeon.

Case complexity did not appear to matter in a stratified analysis. The associations were also robust for other procedure, patient, surgeon, and hospital characteristics.

Limitations included use of administrative datasets that couldn't capture potentially important sociocultural factors, unconscious bias, and communication styles, and didn't address gender as opposed to biological sex.

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