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A view from the coffee room…women do it better

Authors: Virve Koljonen, MD, PhD Department of Plastic surgery Helsinki University and Helsinki University Hospital Helsinki, Finland @plastiikkaope

Since ancient Egypt and ancient times, there have been female surgeons.1  The earliest image of a female surgeon at work was found in the tomb of Ramses II.2  The papyri that survived to the present day show that medicine and surgery in ancient Egypt was systematic, although it was infiltrated with magic and religion. It has been suggested that in ancient Egypt  there were medical specialties and specialised physicians.3 Women surgeons played an active role in the development of surgery and medicine. Women surgeons operated on breast tumours, treated wounds, placed bone fractures in the correct position, performed births, and performed caesarean sections1.  So, everything was going pretty smoothly until the Middle Ages came.

The Middle Ages were not a good time for women surgeons. Women were prevented from training as doctors and surgeons. This has been attributed to male-dominated church and state rulers, which led to a deterioration in the position of women physicians, surgeons, and women1 overall. Women, together with carpenters, smiths and weavers were banned practising surgery and taking part in the Company of Barbers and Surgeons.1 During the Middle Ages, however, there were a couple of exceptional cases when a woman was allowed to practice her profession as a surgeon; if they were found qualified by a “competent” jury.4  Hey, did we just accidentally find the basis for current competency-based specialisation? Another career path for women to achieve the profession of surgeon was death of surgeon husband. Widows of surgeons, were allowed to practice surgery.4  That is, inherit the profession. Fortunately, women continued to practice our profession.

What kind of surgeons are women? Just like their male counterparts. Both sexes have good surgeons and not so good ones. Both have innovative and creative surgeons and those who can keep on doing the same surgery year after year – with good results. We need both kinds of surgeons. Surgery has traditionally been dominated by men.5, 6  Negative biases against women surgeons persist both within surgery and among the general public.6, 7 And thank you for asking, I have had my share of this.

That’s why it was fresh when from both Sweden8 and Canada9 studies were published almost at the same time,  taking a look at how the surgeon’s sex affects surgery results. First, let’s look the Swedish study: female surgeons had better outcomes and fewer complications, although their operations took longer.8 A Canadian study found that patients operated on by female surgeons had fewer postoperative complications, as well as deaths between 90 days and 1 year after surgery, compared to patients operated on by male surgeons.9 To give you an even more broader view, let´s focus our attention on another study from Japan with no difference in complications or deaths between female and male surgeons, even though female surgeons operated on patients in significantly poorer condition.10  The patients women operated on, were more likely to  be older, diagnosed with diabetes mellitus, had dependence in activities of daily living, and lower haemoglobin and albumin levels.10 Male surgeons in this study operated more on patients with preoperative chemo or radiotherapy.10 I really, really don’t want to say this aloud, but it seems that someone was cherry picking. We all inherently know that patients in poor general health, or excluded from oncological treatments due to their general condition, have a higher risk for complications.  

Since then, many attempts have been made to explain the results of these studies.  It has been suggested that the personality of female surgeons is different from that of male surgeons, that the encounter and discussion skills – non-technical skills – of male and female surgeons are different, that the surgical decision-making process, i.e. who to operate on and who not to operate on, is different… This could probably go on for ever, but as long as the issue has not been studied, these are just opinions. Mind you, we cannot say that women surgeon’s technical skills are inferior or superior, since it was not studied. These featured studies are retrospective registry studies and they just reported operation outcomes stratified by surgeon sex.   

Perhaps the surgeon’s speed has been overemphasized in the tradition of surgery. Just remember the speed-blindness and surgeon Liston? In his time, Robert Liston was considered the fastest surgeon in the world,11 with his 30-second amputation. He reportedly achieved 300% mortality in a single operation: the person following the operation died of shock when Liston’s knife almost hit him and Liston accidentally amputated assistant´s finger and the assistant later died of infection; finally the amputee succumbed due to postoperative infection.11  In Liston´s defense, I must remind you that he lived before the era of anaesthetics and pain medications. And surgeons speed was an act of compassion. Hospitals have an electronic system where patients can give feedback, bouquets and brickbats, anonymously. Over the years, I’ve had both. When I’ve looked at my feedback, I have never been praised for my speed as a surgeon – even though I’m fast. Of course, the hospital management system loves speed – the sooner you get rid of one patient and attack the next, the better. As studies have shown, speed does not lead to good results, quite the opposite.

How about this: according to studies, when the surgery was performed by a male surgeon, the female patient had more problems after the operation.12  And lest this remain an isolated observation, the study was repeated in another unit and similarly found that when the surgeon and patient were of different sexes, the results were not optimal.13 My interpretation of all these featured studies, is that we need surgeons of all genders to serve humanity best.  


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