Biases and misperceptions about women as physicians and surgeons by patients and professional colleagues persist in our culture [2, 12]. These predispositions arise from those who question (unconsciously or consciously) whether women are as good as men in roles as physicians and surgeons. The answer is right in the data.
Spoiler alert: Women are as good or better.
Using 30-day mortality as a surrogate for competency, a 2018 study found that women surgeons are as competent as their colleagues who are men. That study of nearly 900,000 patients undergoing 20 common surgical procedures found the adjusted operative mortality for women surgeons was no different than for men, 6.3% versus 6.5%, respectively . And no difference was found when the authors examined the orthopaedic procedures.
In another study of 104,630 matched patients undergoing one of 25 common surgical procedures, patients treated by women surgeons were less likely to die within 30 days (adjusted odds ratio 0.88; [95% CI 0.79 to 0.99]; p = 0.04) . Specifically for orthopaedic procedures, the authors found no mortality differences.
And according to a study of more than 1.5 million Medicare patients for one of eight common medical conditions, older patients had a lower 30-day mortality and lower readmission rates when cared for by women internists . The relative risk reduction for mortality was 4%, which the authors state as “arguably a clinically meaningful difference” .
If you or your loved one were admitted to the hospital and you knew that an attending physician with certain characteristics would influence the risk of death by 4%, would you request such a physician? We would. If you were medical leadership, would you not further study the question of the influence of physician characteristics and behaviors on clinical outcomes in order to elevate all? We would want our leaders to do so but are unaware of such activity. Are our biases that question whether women physicians are as good as men physicians, and hence at some unconscious level doubt the veracity of these research findings, keeping the profession of medicine from learning how to do better?
Why are women internists better physicians than men (when looking at 30-day mortality and readmission rates)? Researchers have postulated that women physicians exhibit skills and behaviors more frequently than men physicians that may promote improved clinical outcomes. Specifically, women are socialized to follow rules from an early age  and do so better than men [1, 3]. Assuming that men and women receive equal training in evidence-based medicine, women are more likely to follow evidence-based medicine guidelines . Researchers suggest that increased adherence to guidelines is a primary reason why patients cared for by women internists have better outcomes .
Women are more patient-centered in their interactions with patients than are men and have skills that may facilitate shared decision making discussions [14, 19]. Women are more likely than men to engage in active listening, a technique which requires that the listener fully concentrate, understand, respond, and then remember what was said  and other partnership-building behaviors that may promote patient engagement . In a fascinating study, men were more likely to comply with treatment plans developed in shared decision making when their physician was a woman . Finally, women are more emotionally intelligent than men leading to greater expression of empathy during patient interactions . This increased level of empathy may in turn lend itself to more robust patient-physician relationships with heightened trust. These studies provide additional support for why women are as good as or better as physicians than men. However, if our biases do not value the skills of effective listening, partnership-building, and empathy as highly as skills such as effective public speaking, leading by authority, and focus on the self, then we will again question whether women physicians are as good as men physicians.
Recognizing the importance of behaviors more strongly demonstrated by women physicians, here is a framework for how all orthopaedic surgeons—both men and women—can advance patient care:
- Incorporate updated evidence-based medicine guidelines into treatment decisions. Evidence-based medicine guidelines help physicians implement scientific evidence into treatment decisions. Following guidelines reduces individual bias, alleviates confusion regarding conflicting evidence, and can support the most cost-effective treatments. In my own practice, I share with my patients with mild knee osteoarthritis that exercise can improve knee pain and function comparable to that reported for oral nonsteroidal anti-inflammatory drugs . Often this is surprising to them and, in my experience, can be effective in motivating the patient to improve their level of physical activity. Evidence-based medicine guidelines can be found online, including the AAOS website, specialty society websites, and UpToDate website.
- Improve patient communication with active listening skills and expression of empathy in patient encounters. Empathy and positive communication can lead to improved patient satisfaction , which may lead to more patient engagement with their care. Increased active listening may also lead to the identification of psychosocial factors that are sources of concern for patients and could interfere with treatment engagement. For men, there is an added bonus: Physicians who are men and who exhibit patient-centered behavior in clinical encounters receive more-favorable patient evaluations than women who exhibit the same behaviors , which the researchers believe reflects biased societal expectations.
- Use shared decision-making with patients. Using shared decision-making during the patient visit increases patient satisfaction with the encounter . Shared decision-making may change the patient-physician dynamic and increase patient engagement. The Center for Shared Decision Making at Dartmouth-Hitchcock provides e-learning courses and other resources for physicians including a toolkit specific to hip and knee osteoarthritis . In addition, the Movement is Life coalition has created a free, web-based shared decision-making tool for patients with knee pain . This innovative tool inputs patient characteristics including gender, race, ethnicity, medical co-morbidities (obesity, diabetes, hypertension) and will show patients’ likely outcomes of differing treatment decisions on their knee pain, physical function and financial productivity and is available at: http://www.movementislifecaucus.com/shared-decision-tool/.
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