Why are we ignoring gender equity in surgery?
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* Edward J. Harvey
* Chad G. Ball

Recently, there have been several excellent Canadian studies looking at gender bias in surgery. They have examined bias at many levels. More specifically, they explored physician referrals, outcomes for similar surgeries in male compared with female patients, and reimbursement at both the physician level and patient disease level.

Wallis and colleagues1 reported on an Ontario database-driven study in *JAMA Surgery*. For a cohort of 1 million patients, patients of female surgeons had fewer complications (e.g., death, hospital readmission, or major medical complications) at 90 days or 1 year after surgery than those of male surgeons. This association was observed across nearly all subgroups defined by patient, surgeon, hospital and procedure characteristics. Despite these findings another cross-sectional, population-based study in Ontario2 reported that male physicians appeared to have referral preferences for male surgeons, with more complex surgeries being referred to males. The authors suggested that this disparity is not narrowing over time or as more women enter surgical disciplines and that such preferences lead to fewer referrals to and lower volumes for female surgeons.

Chaikoff and colleagues3 stated in a recent *CJS* article that in 8 of 11 Canadian medical systems surgeons were reimbursed at significantly lower rates for procedures performed on female patients than for similar procedures performed on male patients. The authors considered this to represent a double discrimination against both female physicians and their female patients.

The findings of these studies are shocking, as the Canada of 2023 prides itself on being an equal society. Taken as a collective, what do these findings truly mean for both Canadian surgeons and their patients? How do we address these findings in our practices and systems in quality-improvement initiatives? Gender equity has yet to be achieved even in the highly educated medical profession. What is the response to follow? Certainly, economic equality for procedures should be easy to solve. Referral patterns for operative versus nonoperative cases will be slower to correct, but will require active management and granular data at a local level. It is now clear that increasing the number of females in medicine and their now scientifically proven competency has not made a difference. The problem is deeply rooted in our society and transcends medicine. It is up to us all to make this a priority. As always, change will come through education and awareness campaigns — but campaigns that have effect. The time is now to deeply examine these issues and offer active and hopefully more appropriate solutions.

## Footnotes

*   The views expressed in this editorial are those of the author and do not necessarily reflect the position of the Canadian Medical Association or its subsidiaries.

*   **Competing interests:** E.J. Harvey is the cofounder and head of medical innovation of NXTSens Inc.; the cofounder and chief medical officer of MY01 Inc. and Sensia Diagnostics Inc.; and the cofounder and director of Strathera Inc. He receives institutional support from J & J DePuy Synthes, Stryker, MY01 and Zimmer. No other competing interests were declared.

This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY-NC-ND 4.0) licence, which permits use, distribution and reproduction in any medium, provided that the original publication is properly cited, the use is noncommercial (i.e., research or educational use), and no modifications or adaptations are made. See: [https://creativecommons.org/licenses/by-nc-nd/4.0/](https://creativecommons.org/licenses/by-nc-nd/4.0/)

## References

1.  Wallis CJD, Jerath A, Aminoltejari K, et al. Surgeon sex and long-term postoperative outcomes among patients undergoing common surgeries. JAMA Surg 2023 Aug. 30 [Epub ahead of print]. doi:10.1001/jamasurg.2023.3744.
    
    [CrossRef](http://canjsurg.ca/lookup/external-ref?access_num=10.1001/jamasurg.2023.3744&link_type=DOI) 

2.  Dossa F, Zeltzer D, Sutradhar R, et al. Sex differences in the pattern of patient referrals to male and female surgeons. JAMA Surg 2022;157:95–103.
    
    

3.  Chaikof M, Cundiff GW, Mohtashami F, et al. Surgical sexism in Canada: structural bias in reimbursement of surgical care for women. Can J Surg 2023;66:E341–7.
    
    [Abstract/FREE Full Text](http://canjsurg.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6MzoiY2pzIjtzOjU6InJlc2lkIjtzOjk6IjY2LzQvRTM0MSI7czo0OiJhdG9tIjtzOjE5OiIvY2pzLzY2LzUvRTUyMC5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=)