Study finds no performance differences between male and female surgeons

A new study published by The BMJ finds no differences in the death rate or complications between male and female surgeons in Japan today, although female surgeons are more likely than male surgeons to refer high-risk patients.

The researchers point out that women remain a minority in surgery worldwide, and they call for more opportunities for female surgeons to reduce gender inequalities.

Although the number of female doctors has increased worldwide in recent years, women remain a minority in surgery.

For example, female general surgeons made up 28% (in 2019), 22% (in 2019), and 33% (in 2017) of surgeons in Canada, the US, and the UK, respectively. In Japan, the proportion of female doctors is 22%, and the proportion of female surgeons is even lower at 5.9%.

However, previous studies in the US and Canada showed that the competence of female physicians and surgeons was equal to or better than that of their male counterparts.

To examine this further, the researchers used the Japanese National Clinical Database (NCD), which contains data on over 95% of surgeries performed in Japan, to compare surgical outcomes by female and male surgeons from 2013 to 2017.

They also examined the association between postoperative mortality (within 90 days of surgery) and surgical complication rates (within 30 days of surgery) and surgeon license terms.

They focused on three common gastric and rectal cancer procedures: distal gastrectomy, total gastrectomy, and low anterior resection. These were chosen because the number of surgeons performing these surgeries was sufficient for analysis without identifying the individual surgeon.

Their analysis included 149,193 distal gastrectomy surgeries, 63,417 gastrectomy surgeries, and 81,593 deep anterior resections.

The researchers found that female surgeons performed only 5% of these procedures, and that female surgeons were less likely than male surgeons to work in high-volume centers.

Female surgeons were more likely to be assigned to high-risk patients (those who were malnourished, were on long-term steroids, or were at a higher stage of disease) than male surgeons.

Despite this, after accounting for other patient-related factors, the researchers found no overall differences in death rates or surgical complications between male and female surgeons.

On average, female surgeons also had fewer years after enrollment and performed fewer minimally invasive (keyhole) surgeries than male surgeons.

The researchers suggest that this may be due to reduced training opportunities resulting from preferential treatment of male trainees and the competing demands of women’s traditional societal roles, including raising a family.

This is an observational study, so no firm conclusions about cause and effect can be made, and the researchers cannot rule out that the results may be due to other unmeasured factors.

They also point to a lack of detail about surgeons’ work and personal living conditions, saying the findings may not apply to other types of surgical procedures or those performed by surgeons with other specialties.

However, strengths of the study included the use of a highly accurate clinical database regarding the patients’ preoperative status and surgical outcomes, as well as the consideration of important patient-related factors for each procedure selected.

“Many aspects can affect the successful development of female surgeons,” say the researchers. “Nevertheless, in this analysis, there was no significant difference in the mortality or complication rates of surgeries performed by female and male surgeons, suggesting that they are equally successful in developing their surgical skills.”

They add, “More appropriate and effective surgical training for female surgeons could further improve surgical outcomes.”

The challenges faced by female surgeons in Japan are not unique, and many female surgeons elsewhere have had similar experiences, notes Cherry Koh, an Australia-based colon surgeon, in a linked editorial.

Changes at the workplace, at home and at the societal level are necessary to support women in the workforce, she says, while leadership at all levels is crucial to drive change, including engagement from government ministers, surgical professional associations, hospital managers and department heads.

It is only through broad commitment that national regulations (such as targets or quotas to support gender equality in recruitment, training and retention) can be combined with local measures (such as codes of conduct, safer workplace practices and mentoring opportunities),” she writes. Rapid change is required in the interest of doctors and patients.”