Gender Bias in the OR Is a Hazard to Patient Safety

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It was a typical bustling morning in the pre-operative area where I was waiting for my patient to go back to the operating room (OR). I was reviewing my day ahead: after a short procedure in the OR, I had a full clinic day with multiple office procedures, and then was leaving immediately for an international conference where I would be teaching a course the next morning. At 7 a.m. I was walking back to the room to make sure they had my equipment when my cell phone rang. It was the OR command center.

“We’re bumping you.”

Surgeons are used to hearing these words. Things happen, emergencies come in, and schedules need to be rearranged. However, bumps typically come from a surgeon-to-surgeon request and usually happen within the same specialty.

“Oh, is there an emergency?” I asked.

“No, Dr. ‘Big-Name’ wants to start his case at 8 a.m. in that room, so we’re bumping you. You need to tell your patient.”

I was incredulous. Why didn’t Dr. Big-Name call me himself? Why would he bump another service? Why doesn’t he start at 7:15 a.m. like everyone else? Why does his elective case dictate what happens to mine? These thoughts ran through my mind as I slowed to a stop.

“No,” I said.

“Excuse me?!”

“No, I can’t move today.”

I went on to explain my packed schedule and international flight that afternoon.

“If you bump me, the patient gets cancelled. She’s sitting here in pre-op with an IV. So someone from the command center will need to come explain why she’s getting cancelled for another surgeon’s elective case.”

Silence …

“Okay, make it quick.” <Click>

My story is not rare. It spans regions and institutions. Every female surgeon could tell you a similar one. More and more organizations are bringing light to this issue.

It’s well studied that women in surgical specialties face immense barriers to career advancement. Women compose half of current medical school classes, yet successful recruitment into surgical training is lacking. Even when women are recruited into a surgical specialty, there is difficulty in retaining them due to gender bias and various obstacles to career advancement, including lower rates of surgical residency completion, board certification, and professional advancement, and they are graded more harshly in academic evaluations. Women surgeons experience less achievement, are more dissatisfied, and have higher levels of burnout compared with their male colleagues.

One of the contributing factors could be the female experience in the OR. Interprofessional teamwork is critical to success in medicine, particularly in intense work environments such as the operating room. Interprofessional conflict is known to contribute to workplace dissatisfaction and stress, and existing data suggest women are more likely to experience these conflicts. For example, surgical technologists file complaints against women more often than men. Language in those complaints indicates gender bias. Similarly, in a study looking at decision-to-incision time for ovarian and testicular torsion, it took almost double the time for female patients to get to the operating room as male patients, even after a decision for surgery was made. Female surgeons are more likely to take care of female patients. When female surgeons are discriminated against, it affects female patients and vice versa. It’s a physician issue and, more importantly, a patient safety issue.

Amani Jambhekar, MD, MBA, a breast surgical oncologist, recently noted her experience on Twitter:

“Noticed a retractor was broken. OR nurse tells me to make it work instead of opening another. Stated I wasn’t competent or resourceful when I insisted on having functional equipment. Male surgeon w/ me asks for ‘less sticky’ Adsons, she gets him another set, no commentary.”

Toxicity and delays in the OR are an important patient safety issue. A delay in getting properly working equipment, for example, means that the patient undergoes more anesthesia. Psychological safety has a significant impact on whether a team member will speak up in a high stakes work environment. Microaggressions and bullying erode psychological safety, making a team more prone to errors.

Outside the OR, female surgeons are also graded more harshly by their referral base: physicians increase their referrals more to a male surgeon than to a female surgeon after a good patient outcome but lower their referrals more to a female surgeon than a male surgeon after a bad outcome. Other data show a large discrepancy in both research funding and overall compensation between male and female surgeons. Despite this, there is evidence showing that female surgeons have more favorable patient mortality outcomes than male surgeons.

Even when women become the majority in a specialty, it does not necessarily change the culture. Gynecologic surgeons are the lowest paid and most poorly reimbursed of any surgical specialty. When case-matched for equivalent procedures on male bodies, gynecologic surgery coding gets reimbursed 28% less despite the lack of evidence that procedures on females are less complex. This means gynecologic procedures are less valuable to the hospital’s bottom line. Gynecologic surgeons of all genders can recount times when their procedures were delayed, bumped, cancelled, or assigned untrained staff to accommodate procedures in other specialties. This gender discrimination against patients is unacceptable and unethical.

More data are needed on how gender discrimination in the operating room affects patient outcomes. Microaggressions, delays, and team conflicts should be reported, just as other patient safety issues are. They should be reviewed on a regular basis similar to a morbidity and mortality conference, with the goal of implementing process improvements and systemic change. OR boards, hospital schedules, and operating rooms are not run by robots. They are run by humans with bias. Until this bias is measured and brought to light, it will continue to be the norm.

When I finished my case that morning, the female circulating nurse and scrub tech, both of whom I’d never worked with before, thanked me for advocating for my patient. “We’re glad we got to work with you. You’re much nicer than Dr. Big-Name.” We can change the system if only we are brave enough to stand up to it.

Kelly Wright, MD, is director of the Division of Minimally Invasive Gynecologic Surgery and an associate professor in the Department of Obstetrics and Gynecology at Cedars-Sinai Medical Center in Los Angeles.

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