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Comparison of postoperative outcomes among patients treated by male and female surgeons: a population based matched cohort study

BMJ 2017; 359 doi: https://doi.org/10.1136/bmj.j4366 (Published 10 October 2017) Cite this as: BMJ 2017;359:j4366

Re: Comparison of postoperative outcomes among patients treated by male and female surgeons: a population based matched cohort study

Firstly I would like to thank the authors for writing this stimulating article. I have a few general comments and some critique.

By stipulating that “the care provided by an inpatient internal medicine service is performed by a team” and “by contrast … the primary surgeon has a direct effect on patient outcomes” could be seen to infer that surgery is not a team effort. Which is of course not true. In fact in training hospitals the primary surgeon may be overseeing or supervising a junior colleague carrying out the majority of the procedure. More senior trainees are often responsible for opening and closing with the surgeon of record on site but unscrubbed. So the surgeon of record for analysis may not have performed the entire operation from start to finish.

I am critical of the exclusion of the 8753 patients treated by physicians whose primary declared specialty was non-surgical. I am unfamiliar with how the primary specialty is declared in Canada. However, if the declaration is in any way similar to in the UK this could exclude a vast number of cancer patients. The primary specialty is often the physician overseeing the multidisciplinary team meeting at the time of initial diagnosis, such as haematology, oncology, respiratory medicine, gastroenterology and many more. This exclusion has the potential to augment results relating to all outcome measures given the morbidity and mortality associated with malignancy. There is no mention in the limitations of the large number of patients excluded because the treating institution could not be identified. Allowing for the other exclusions this represents 4.47% of the true sample size and could contain significant data pertinent to the results.

This article contributes to a growing body of observational research into sex and gender issues in the wider medical field. I think it’s important that the authors acknowledged that they were unable to identify transgender surgeons, given that they used biological sex at the time of registration as means of categorisation. Accepting this study limitation, it is possible that trans female surgeons are being analysed within the male group and trans males in the female group. The authors state “female and male physicians differ in their practice of medicine” with “female doctors being more likely to use a patient centred approach and to follow evidence based guidelines”. Given that there is more than just biological determinism of gender, the practice and approach of trans surgeons may differ significantly from their natal sex and align more with their gender. I concede that transgender surgeons who transitioned since registration are likely to represent an incredibly small proportion of this cohort. However, it is my belief that transgender surgeons’ outcomes should be analysed within the category of their self-assigned gender. To analyse them within their natal sex group is to potentially underestimate the results.

Competing interests: No competing interests

13 October 2017
Josephine C Weaver
Junior Doctor
Melbourne, Australia