About a year ago, Yusuke Tsugawa – then a doctoral student in the Harvard health policy PhD program – and I were discussing the evidence around the quality of care delivered by female and male doctors. The data suggested that women practice medicine a little differently than men do. It appeared that practice patterns of female physicians were a little more evidence-based, sticking more closely to clinical guidelines. There was also some evidence that patients reported better experience when their physician was a woman. This is certainly important, but the evidence here was limited to a few specific settings or in subgroups of patients. And we had no idea whether these differences translated into what patients care the most about: better outcomes. We decided to tackle this question – do female physicians achieve different outcomes than male physicians. The result of that work is out today in JAMA Internal Medicine.
Our approach
First, we examined differences in patient outcomes for female and male physicians across all medical conditions. Then, we adjusted for patient and physician characteristics. Next, we threw in a hospital “fixed-effect” – a statistical technique that ensures that we only compare male and female physicians within the same hospital. Finally, we did a series of additional analyses to check if our results held across more specific conditions.
We found that female physicians had lower 30-day mortality rates compared to male physicians. Holding patient, physician, and hospital characteristics constant narrowed that gap a little, but not much. After throwing everything into the model that we could, we were still left with a difference of about 0.43 percentage points (see table), a modest but clinically important difference (more on this below).
Next, we focused on the 8 most common conditions (to ensure that our findings weren’t driven by differences in a few conditions only) and found that across all 8 conditions, female physicians had better outcomes. Finally, we looked at subgroups by risk. We wondered – is the advantage of having a female physician still true if we just focus on the sickest patients? The answer is yes – in fact, the biggest gap in outcomes was among the very sickest patients. The sicker you are, the bigger the benefit of having a female physician (see figure).
Additionally, we did a variety of other “sensitivity” analyses, of which the most important focused on hospitalists. The biggest threat to any study that examines differences between physicians is selection – patients can choose their doctor (or doctors can choose their patients) in ways that make the groups of patients non-comparable. However, when patients are hospitalized for an acute illness, increasingly, they receive care from a “hospitalist” – a doctor who spends all of their clinical time in the hospital caring for whoever is admitted during their shift. This allows for “pseudo-randomization.” And the results? Again, female hospitalists had lower mortality than male hospitalists.
What does this all mean?
The first question everyone will ask is whether the size of the effect matters. I am going to reiterate what I said above – the effect size is modest, but important. If we take a public health perspective, we see why it’s important: Given our results, if male physicians had the same outcomes as female physicians, we’d have 32,000 fewer deaths in the Medicare population. That’s about how many people die in motor vehicle accidents every year. Second, imagine a new treatment that lowered 30-day mortality by about half a percentage point for hospitalized patients. Would that treatment get FDA approval for effectiveness? Yup. Would it quickly become widely adopted in the hospital wards as an important treatment we should be giving our patients? Absolutely. So while the effect size is not huge, it’s certainly not trivial.
A few things are worth noting. First, we looked at medical conditions, so we can’t tell you whether the same effects would show up if you looked at surgeons. We are working on that now. Second, with any observational study, one has to be cautious about over-calling it. The problem is that we will never have a randomized trial so this may be about as well as we can do. Further, for those who worry about “confounding” – that we may be missing some key variable that explains the difference – I wonder what that might be? If there are key missing confounders, it would have to be big enough to explain our findings. We spent a lot of time on this – and couldn’t come up with anything that would be big enough to explain what we found.
How to make sense of it all – and next steps
Our findings suggest that there’s something about the way female physicians are practicing that is different from the way male physicians are practicing – and different in ways that impact whether a patient survives his or her hospitalization. We need to figure out what that is. Is it that female physicians are more evidence-based, as a few studies suggest? Or is it that there are differences in how female and male providers communicate with patients and other providers that allow female physicians to be more effective? We don’t know, but we need to find out and learn from it.
Another important point must be addressed. There is pretty strong evidence of a substantial gender pay gap and a gender promotion gap within medicine. Several recent studies have found that women physicians are paid less than male physicians – about 10% less after accounting for all potential confounders – and are less likely to promoted within academic medical centers. Throw in our study about better outcomes, and those differences in salary and promotion become particularly unconscionable.
The bottom line is this: When it comes to medical conditions, women physicians seem to be outperforming male physicians. The difference is small but important. If we want this study to be more than just a source of cocktail conversation, we need to learn more about why these differences exist so all patients have better outcomes, irrespective of the gender of their physician.
Ashish K. Jha
Categories: Uncategorized
Just curious: who funded this research and how much? Looks like NIH (taxes) funded one author… did others do it for kicks?
This is great! Our family doc is a woman.
Absolutely awful study. Poor data, poor controls and whats the point? If we did a study that white males made better surgeons than Indian females, how would that fly? Why even do it? Its ridiculous and divisive. I am shocked that anyone would do such a study in 2016. Lets just stop this. We are better than this.
Andrew Barnett and Stephen Soumerai: agreed…..and this blog site is populated by M.D.’s, Ph.D’s etc who ought to know better. But even we give in to these kinds of weak trendy “studies”….just think what the popular press medical journalists do. Oh well, we all are subject to human nature to pay attention to such things….all in all an amusing diversion.
Data is data and reveals a slight, questionably significant, though consistent difference in outcomes. The conclusions however are not supported by the data unless you assume that women and male physicians are monolithic. Study is flawed and conclusions are junk science. Fortunate for the investigator that the “results” were politically correct, or efforts to promote the study in the mass media would have been social suicide.
On the plus side, the attention of the flawed study may focus attention on the differences in compensation and promoting patterns, which other studies have shown reveal unacceptable inequities.
Weak design, causal conclusion, 0.4% “effect,” unadjusted severity diffs, no mechanism, authors want others to figure out why, media frenzy
It could be that a nurturing person is better at communicating accurately, a not necessarily precise distinction between the sexes, usually but not always. Back to the beginning, what is a “caring relationship” This question would likely lead to a wide variety of answers. Here.’s mine:
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A “caring relationship” may be defined as a variably asymmetric interaction occurring between two persons who share a ‘beneficent’ intent over time to enhance each other’s ‘autonomy’ by communicating with warmth, non-critical acceptance, honesty and empathy.
I would further offer my own view that the caring relationship is the fundamental ingredient for good healthcare.
https://feminem.org/2016/12/19/femineverything-can-say-women-doctors-just-better-everyone/
I’ll offer a patient’s perspective. First, I assume there are no differences between male and female doctors in IQ, diagnostic skills, ability to use resources like Up to Date, etc. Adherence to evidence based guidelines and protocols could potentially be problematic if it’s too rigid. If the mentality is I’ll deviate from the guidelines if, in my judgment, they’re not applicable or appropriate in this particular case, that’s fine. If the attitude is that I can completely ignore guidelines because I’ve been practicing for 20 or 30 years and I know what I’m doing and I don’t practice “cookbook medicine,” that’s not so fine.
If I had to guess, I think the most relevant factor driving the slightly better outcomes among female physicians is communication style and skills. If the doctor is seen by the patient as kinder, gentler, more empathetic and patient, there may be a better response in terms of compliance with instructions, will to live, willingness to fight to recover, etc. The female instinct for nurturing is something that male doctors probably can’t easily replicate even if they wanted to at least at the population level. This is all merely opinion and conjecture on my part. I can’t prove it or back it up in any way.
Moreover, my own doctors all happen to be male and I’m very satisfied with each one of them because they’re excellent in their field and can communicate very effectively with both me and my wife about my medical issues.
The NPI number match was such a major part of the study that better understanding would appear to be indicated when the physician matched may not accurately reflect the care especially in hospitalists.
The 30 day mortality outcome has a contribution regarding outcomes shaped by patient, community, resource, and other factors before and after hospitalization. More about this contribution and the ability of controls to address this would be helpful.
What type of bias is introduced when using proxy variables for the patient such as median income for the zip code of the patient rather than actual income?
Data missing for 47.4% of physicians is concerning and could introduce bias. Most likely this is the area of race/ethnicity data. Why is Asian missing? Did you do analyses with fewer physician variables to allow use of a more complete sample?
The consistent differences between males and females argue for consistent differences such as physician age, physician origins, and physician practice locations and types. The patients will also be different according to physician gender. Female physicians are more likely to be from higher income more urban counties and are also more likely to be found in same. This seems to be true regarding the female vs male physicians in the study by type of practice and location.
Across family medicine graduates the females were 3 to 5 percentage points less likely to distribute to rural or lower physician concentration counties compared to males across race/ethnicity. Shifting patients down the SES scale would clearly demonstrate differences in outcomes. There would be differences in available consultants, hospital resources, community resources, and local workforce post hospital. There would also be differences in areas such as diabetes, obesity, sedentary lifestyle, preventable deaths – worse where physician concentrations and many other concentrations are less to least.
DO vs MD does not seem important, but US born or International Graduate seems quite relevant. US birth origin is in the AMA Masterfile source database. Medical school categories could be useful. Can the results be explained by English as a second language as in international medical graduates – important since internal medicine has so many? The male internists may well be more likely to be ESL. International graduate internists have had higher board scores but have had higher discipline rates. Mismatches of physicians to the populations of their practices could impact outcomes. Andriole in JAMA prematriculation studies (also convenience data studies) did indicate differences such as higher academic difficulty rates in Hispanic, Asian, and male students – but there were no controls for English proficiency. This is a problem if you want to attribute outcomes to such variables.
If clinical interventions are the right way to go (such as eliminating males from practice, decreasing resident handoffs), then the complicated analyses are helpful.
If, however, the outcomes are mostly about patient/community/system/resource factors, then we have been wasting tens of billions more each year adding to additional costs and we will be delaying real solutions for outcomes not only in health care but in education, economics, and other areas.
It is clear that health care going from 1 to 2 to 3 trillion and beyond is collapsing domestic discretionary spending in the areas most likely to shape outcomes. To Err is Human to MACRA and beyond may turn out to be the opposite of value based with substantially more spent for little change in outcomes.
David writes:
Ask yourself this: could a paper with the opposite conclusion to Jha’s (i.e. same paper with the genders reversed) ever be published? Would anyone in academia be foolish enough to try to publish such result – and would such a manuscript ever make it into a peer-reviewed publication, and similarly celebrated by the media?
To practice science is to appreciate the extent to which science occurs in a social context, and to recognize that all findings are not created equal. Results that support conclusions the community wants to believe almost certainly face a lower bar to publication than work that threatens to endorse or legitimize unpopular beliefs.
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One part of me has a problem with this study.
Another part says, “yes” makes sense. The finding completely coincides with my own observations. So there’s that ..
So I don’t know what the answer is here.
I would like to know your mindset, Ashish, when you began writing this article. E.g. if your conclusuons just happened to be that men were better than women, you could never have published the results. It would have been a PC no-no. Also, aren’t the genders off limits? ….as are the races and the IQs and the LGBTs? What if I wrote a similar piece showing that gay hispanic women were superior doctors compared to transexual progressives? Wouldn’t I be ridiculed?
I’m being a little whimsical, but I do wonder how you got away with it?