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A female surgeon may be slightly more likely to produce better outcomes after surgery, a retrospective study suggested, though it remains unclear if confounding factors play a role in this apparent advantage.

Canadian patients who underwent one of 25 procedures performed by male and female operators were matched by age, sex, comorbidities, and other baseline characteristics, reported Raj Satkunasivam, MD, of Houston Methodist Hospital, and colleagues.

The combined death, readmission, and complication rates within 30 days of surgery were (11.1% versus 11.6% for male surgeons, adjusted OR 0.96, 95% CI 0.92-0.99), they wrote in The BMJ.

Driving this finding was a difference in mortality at 30 days (0.9% vs 1.0%, adjusted OR 0.88, 95% CI 0.79-0.99), they stated.

Patients stayed the same median 2 days in the hospital in both groups, but female surgeons were still associated with a small statistical advantage (adjusted OR 0.97, 95% CI 0.94-0.99).

On the flip side, surgeon sex made no difference in readmissions (4.7% versus 4.8%, adjusted OR 0.96, 95% CI 0.91-1.02) or complications (6.8% versus 7.0%, adjusted OR 0.96, 95% CI 0.92-1.01).

Accounting for different patient, physician, and hospital characteristics did not sway the main findings, Satkunasivam's group found, but a subanalysis on emergent operations did.

"Our retrospective analyses of emergent operations, where patients are less likely able to select or be biased towards a surgeon of a particular sex, partly support the possibility of confounding. We found that the benefit in composite outcome for patients treated by female surgeons was restricted to elective procedures," they noted.

"Regardless, outcomes for patients treated by female surgeons were never worse than for those treated by male surgeons," they stated.

That was an important point that Clare Marx, MBBS, and Derek Alderson, MD, respectively the immediate past and current presidents of the Royal College of Surgeons in London, highlighted in an .

"Surgery is a specialty that continues to struggle with unconscious bias among patients and health professionals, and gender inequality persists. In this large Canadian study only 23.4% of surgeons were female, and only 12.4% of patients were treated by women," they wrote. "This study helps to combat these lingering biases by confirming the safety, skill, and expertise of women surgeons relative to their male colleagues."

Satkunasivam's group collected the records of all patients receiving one of 25 surgical procedures in Ontario, Canada, from 2007 to 2015 (n=104,630). On baseline, those undergoing a procedure with a female surgeon were themselves more likely to be women and tended to be younger than those whose surgeons were men. After matching, groups became well balanced.

"We found an association between improved 30 day postoperative outcomes and female surgeons, but whether these differences would persist for long term survival is unclear. We focused on short term outcomes, as others have previously done, because technical factors related to the surgeon are more likely to contribute to complications in the immediate postoperative period rather than to long term surgical outcomes," the authors explained.

They acknowledged the possibility of unmeasured confounding in their study, as well as a lack of data on the complexity or severity of disease.

Yet even if the reported sex difference really existed among surgeons, does it matter? Patients don't tend to focus on short-term outcomes, argued Marx and Alderson.

"Improving surgical outcomes is a complex undertaking. Surgeons and researchers tend to focus on physical and clinical endpoints, often failing to acknowledge the importance of the social and emotional outcome after surgery. Hospital providers are more concerned with cost effectiveness and efficiency savings than community costs," they pointed out. "With so many critical factors to consider, trying to find out why there is a very small difference in short term clinical outcomes between male and female surgeons is unlikely to prove worthwhile."