Hospitalized Patients Treated by Female Doctors Show Lower Mortality

Yves here. Bear in mind that this finding applies to hospital settings and should not be generalized beyond that.

Some readers in comments theorized that this might be due to the fact that women are better listeners. And while that sort of gender stereotyping bothers me, in fact, women are acculturated to curry favor with men (both for the obvious reason of gaining advantage socially and from a reproductive strategy standpoint, as well as to avoid getting men angry, since they will typically win in a physical fight).

But the article also points out that “women are promoted less frequently”. Thus it may simply be that the women doctors on the front line in hospitals are better on average by virtue of having not been given promotions that they deserved. Women in similar fields are subject to pronounced discrimination. For instance, for a woman to get tenure in the sciences, she has to have written 2.5 times more articles that were published in peer-reviewd journals than men.

By Gaius Publius, a professional writer living on the West Coast of the United States and frequent contributor to DownWithTyranny, digby, Truthout, and Naked Capitalism. Follow him on Twitter @Gaius_Publius, Tumblr and Facebook. Originally published at at Down With Tyranny. GP article archive  here. Originally published at DownWithTyranny

We’re getting off the Trump Train for a minute for something remarkable. I was bowled over by the results of this study and wanted to pass them on. From the Harvard School of Public Health:

Hospitalized patients treated by female physicians show lower mortality, readmission rates

Boston, MA – Elderly hospitalized patients treated by female physicians are less likely to die within 30 days of admission, or to be readmitted within 30 days of discharge, than those cared for by male physicians, according to a new study led by researchers at Harvard T.H. Chan School of Public Health. It is the first research to document differences in how male and female physicians treat patients result in different outcomes for hospitalized patients in the U.S.

The researchers estimated that if male physicians could achieve the same outcomes as their female colleagues, there would be 32,000 fewer deaths each year among Medicare patients alone—a number comparable to the annual number of motor vehicle accident deaths nationally.

The study was published online December 19, 2016 in JAMA Internal Medicine.

There’s more. The sickest patients appear to benefit most from treatment by female doctors:

“The difference in mortality rates surprised us,” said lead author Yusuke Tsugawa, research associate in the Department of Health Policy and Management. “The gender of the physician appears to be particularly significant for the sickest patients. These findings indicate that potential differences in practice patterns between male and female physicians may have important clinical implications.”

The study offers some clues as to why this is the case, noting that “for example, female physicians are more likely to adhere to clinical guidelines and provide more patient-centered communication.” But it also notes that much more information is needed.

For example, “patient selection” is not a factor: “When the researchers restricted their analysis to hospitalists — physicians focused on hospital care, to whom patients are randomly assigned based on work schedule — the results remained consistent, suggesting that patient selection, in which healthier patients might choose certain types of doctors, didn’t explain the results.”

One of the differences between male and female doctors is that, as you might imagine, women doctors are paid less and promoted less frequently. Another, noted above, is their communications styles tend to differ, with female physicians communicating in a more “patient-centered” manner.

It’s not known, though, whether these factors account for the difference in outcomes. “There was ample evidence that male and female physicians practice medicine differently. Our findings suggest that those differences matter and are important to patient health. We need to understand why female physicians have lower mortality so that all patients can have the best possible outcomes, irrespective of the gender of their physician,” said senior author Ashish Jha.

Indeed. The data for the study included information from more than one million Medicare patients, and their experiences are remarkable: “[I]f treated by a female physician, [patients in our study] had a 4% lower relative risk of dying prematurely and a 5% lower relative risk of being readmitted to a hospital within 30 days.”

Something to consider, perhaps, as you consider your own treatment options and those of your loved ones.

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  1. Knifecatcher

    I have no expertise in this area but have seen a number of online discussions regarding “eminence based” vs “evidence based” medicine. That is, some portion of the medical profession prescribes treatment based on the learned doctor’s experience and intuition, even when that contradicts well established clinical best practices.

    Maybe the pattern is that female doctors tend to be less ego driven and that’s why they stick to the guidelines. That seems to fit with the relatively lower pay / seniority vs their male counterparts.

    1. marymac

      I disagree. Women are not stuck in the ego box in the same way men are. Women have room to be more creative/deep in their thinking and get better results.

  2. LifelongLib

    It’s been suggested that elementary schools were better 50 years ago because they were staffed by women who in today’s world would be college professors, and that businesses then benefited from having women secretaries who would now be executives or CEOs. Maybe these women physicians are another example of nominally low-level people actually being very important. But rather than using discrimination to keep smart people in mundane jobs, we should start recognizing and paying them what they’re actually worth for the work they’re already doing.

    1. Cry Shop

      smart people in mundane jobs, we should start recognizing and paying them what they’re actually worth for the work they’re already doing.

      Most of the smart people I know would not stay in mundane jobs for more money, so is it right to just pay them more money to make them feel better about being told, stay where you are, woman. If on the otherhand, they don’t view these jobs as “mundane” at all, but give them up for better pay, then you have a point, they should be better paid, if society values them at that job.

      However that’s not going to happen in a heavily capitalist system, so what I’d say is these are just one more example of why capitalism and market based solutions are failing.

      1. tegnost

        you may be confusing smart with ambitious, there are plenty of smart people in all walks of life, as well as the alternative not so smart group, so I might say that it’s more like ambitious people are unlikely to stay in what they consider mundane jobs because they have bigger plans for themselves. Some smart people recognize the rube goldberg nature of it all and choose to just have a good life even though an outsider with different goals may call that mundane.

        1. Cry Shop

          I’m not sure if your replying to me or the first comment in this branch. The content of your comment indicates you’ve misinterpreted both comments.

          1. tegnost

            there are large numbers of so called smart people who have mundane jobs that they keep for the money, money given to them as they are credentialed, i.e., smart, and in many cases they achieved he credentials because they are/were ambitious. They are in those mundane jobs for money, thus my disagreement with you and not so much with the original poster who questions the current distributions in the meritocracy. Nothing personal, but smart ain’t all that and these days borders on being a buzz word.

            1. Cry Shop

              mundane: lacking interest or excitement; dull.

              Sounds to me as it those are user defined, and no smart, or intelligent person will remain at any job they find mundane. Others are no so luck at birth and have to make do with mundane employment. Empathy is key, it’s the person being objectified who has to make that decision.

              Anecdotally, I’ve picked many M.S. and PhDs, working on my 12th right now, and I’m well past US retirement age. I have held different jobs over my life because any job for me eventually becomes mundane and I’ve had the intelligence to secure what I wanted. I’m most certainly not alone. I also understand very well there are a lot of people who do jobs they hate, because life.

            2. Yves Smith Post author

              The best job at McKinsey was being an engagement manager. That’s the role for people 3-5 years at the firm. This was widely acknowledged by partners.

              Similarly, most journalists prefer doing reporting to being promoted to editor.

              Admittedly these are good white collar jobs, but so is being a doctor. The less senior roles are hands on. More senior roles involve politics and going to lots of pointless meetings. But they have more prestige and pay better.

    2. Optimader

      I would look for a correlation to admin/teacher ratio, teaching plans sans technological clutter (computers). I had few male elementary schoolteachers but they were as good or better than certain female counterparts. HS, I would make no gender related correlation as well.

  3. PlutoniumKun

    The study is very intriguing, I was very interested when I first heard of this study as there are a few medics and aspiring medics in my family.

    One possible issue is that from my outside observations, the best female medical students often seem to be encouraged to go for more ‘hands on’ specialisms, while the best male doctors often for for the more ‘techie’ specialities like neurology or radiology. One family member was repeatedly advised to specialise in geriatrics as she was told she had particular skill with old patients, when her real interest was in neurology.

    Another form of subtle ‘sorting’ of young doctors is related to an issue that was in the discussions yesterday – about how women are more inclined to go into professions – or niches within professions – which have more family friendly hours. I know from another family member who works in medicine that there is a strong tendency for female doctors to go for hospital jobs rather than as single family practitioners, because the former are seen as being more ‘9 to 5’. So it may be that the more empathic, patient oriented male doctors are not being included in the study as they are going out into small practices or clinics, while the best female doctors are in hospitals.

    1. ekstase

      I’ve been thinking about this and of several good, empathetic male doctors I’ve had, but these were all highly recommended and in small private practices. I wonder if this would be very different in a hospital setting, esp. with end of life care, when patients have fewer choices as to who treats them. I also wonder how fast someone would discard their sexism if they knew doing so might help their medical outcome.

  4. Cry Shop

    The researchers estimated that if male physicians could achieve the same outcomes as their female colleagues, there would be 32,000 fewer deaths each year among Medicare patients alone—a number comparable to the annual number of motor vehicle accident deaths nationally.

    What happens to these people, do they eventually age out of Medicare? What’s postponed is death, they are not handed eternal life (I hope – what a horror, the idea of never being allowed to expire).

    This is what happens when laymen journalist/news-reporters are faced with maths/stats, they mess it up. Even if these 32,000 people achieved a significant extension of life, then in the next year or so population death rates will revert to the norm (or actually a bit higher, if this is a one off-blip). A better measure is to see what was achieved with span of life.

    What if the issue of perhaps male doctors are more willing to not exercise extreme measures to sustain life for those who’s quality of has gone to hell in a basket (or get sicker patients). All in all, I don’t find these sorts of numbers take in isolation very helpful.

    1. PlutoniumKun

      What if the issue of perhaps male doctors are more willing to not exercise extreme measures to sustain life for those who’s quality of has gone to hell in a basket (or get sicker patients)

      That’s a very good point. Its no secret that the lifespan of ‘end of life’ patients can vary extremely widely between doctors and it has nothing to do with the doctors skill. I’ve personal experience of witnessing young inexperienced doctors hesitating to accept a ‘do not resuscitate’ instruction on a medical chart. And its also possible (I haven’t read the original study so I can’t comment) that as older more experienced doctors are likely to get the worst cases, then if there are more older male doctors (likely), this could skew the figures. There are numerous possible sources of bias in a study like this. Its still very interesting though.

      1. Cry Shop

        Not just experience, but financial security too. My first PhD is Nuclear Medicine, which was suppose to be done in tandem with an MD. Quit the later program because I got mentally exhausted dealing with medicine for profit, and being abused every time I tried to stop it. Seen plenty of cases where cancer patients weeks or even days from death were scheduled for procedures as extreme as limb amputations, etc. because everyone but the patient stood to benefit. Dr. got more money, family of patient felt they had done their best, etc; but the patients last days were loaded with the extra pain and insult from the procedure. Occasionally the really senior doctors, the ones everyone else feared, would call bullsh*t. Not a lot, but maybe enough to explain those pretty small deviations in outcome the original article. I’ve seen a lot of medical equipment/supply OEM’s use these kinds of numbers in isolation to do all kinds of abuse.

        1. PlutoniumKun

          Thankfully, I’m in Europe and the financial incentive to keep dying people alive isn’t so strong here, although what that means is that there is often a variation between those doctors who keep people alive for other reasons (sometimes religious, sometimes just because they feel that’s what they should do), and the subjective ethical problem faced by the others of when exactly to call a halt to treatment. Patients have an input too. A cousin who recently died from cancer insisted on additional treatment against the advice of two oncologists. A medic relative said it probably added 3-6 months to her life.

          I’ve often wondered how much US mortality rates are skewed compared to other countries by the financial incentive to keep people alive. I’m not aware of any studies into it.

            1. PlutoniumKun

              There can be no doubt that it is one reason why the US spends something like 17% of GNP on health, whereas most other developed countries spend around 8-12%. The US health system is of course designed to enrich the service providers. But a quick scan of WHO figures indicates that while the US scores relatively poorly in individual measures of healthcare, such as infant or maternal mortality, it is fairly average in overall life expectancy (its no. 31).

              My suspicion would be that this is because of intensive treatment of the already terminally ill, but I’m not aware of any studies on this.

              1. TheCatSaid

                There was a famous study or survey about this (Seattle? nursing?) about 20 or 30 years ago. It led to a change in the directions of public healthcare spending, to prioritize healthcare spending for children/youth/maternity and prevention, as opposed to heroic end-of-life measures which was cost intensive in relation to outcomes.

        2. Katharine

          >family of patient felt they had done their best

          This is why families need to talk a lot earlier, and be tough-minded when they think doctors are wrong. The medical director of a nursing home said categorically my father would die in six months of aspiration pneumonia if he didn’t have a gastric tube inserted. We considered, noting that my father was a man who did not like being interfered with, and said no tube. He died fourteen months later of congestive heart failure, having eaten well and without further pneumonia during most of that time, and I mentally thumbed my nose at the medical director as he certified the death.

          I think that for doctors as well as kin, doing your best ought to be defined more holistically than in terms of maintaining a heartbeat for the longest possible time. I don’t know whether women doctors are more likely to think in those terms, but whatever makes doctors think that way should be encouraged.

          1. PlutoniumKun

            I don’t know whether women doctors are more likely to think in those terms, but whatever makes doctors think that way should be encouraged.

            The original study says that several previous studies indicate that female doctors tend to go more ‘by the book’ when treating patients. As to whether this indicates that male doctors are more ‘holistic’, or whether they just have excessive confidence in their own judgement isn’t said, although its strongly implied that the latter is the case.

            1. Katharine

              Manifestly this doctor was not more holistic! He would have been less trouble if he had been, but as for excessive confidence, he had plenty of that.

    2. Oaf

      …maybe having a female doctor helps more patients find reason to survive!
      Agreed; death is only deferred; not prevented. So, study is BS on that level; but something there in spite of botched premise.

  5. The Trumpening

    My suspicion, and I could be wrong, is that if a study showed male doctors saving more lives than females then the study wouldn’t be published. Which makes me wonder if other studies indeed showed male doctors saving more teenagers or young adults, for example, but were surpressed for obvious reasons ?

    My guess on the older patients is that male doctors are more apt to play God by letting certain old timers pass away even when they could theoretically be saved.

  6. nothing but the truth

    it is more likely that patients who are more seriously ill are referred to male doctors are they are seen as more competent.

    1. Cry Shop

      It’s something more subtle.

      “For example, “patient selection” is not a factor: “When the researchers restricted their analysis to hospitalists — physicians focused on hospital care, to whom patients are randomly assigned based on work schedule — the results remained consistent, suggesting that patient selection, in which healthier patients might choose certain types of doctors, didn’t explain the results.””

    2. Dugless

      This was controlled for in the study. Patients were matched on severity of illness. A common response to poor outcomes by physicians when compared to peers is that “my patients are sicker” however this is rarely true. This is unlikely to be the reason for the findings in this study. It is most likely that the doctors who adhered to protocols have better outcomes. I would guess that female doctors are less likely to break protocols, either due to ego issues or possibly age. I find younger physicians are more likely to practice evidenced-based medicine and more likely to adhere to evidence-based protocols. I would guess that the average age of female MD’s is lower as there are increasing numbers of women entering the profession over time. BTW, I am a physician with 20 plus years of experience as is my wife.

  7. Terry

    I echo the points regarding physician specialist. Orthopaedics is male dominated (historical reasons and because it’s possibly the specialty requiring the most physical strength). “Catastrophic decline” and death following otherwise successful total joint replacement is a known problem but which cannot be predicted a priori by the typical mobility questionnaires. My former boss (who literally wrote the key rheumatology textbook) suspects psychosocial factors, things that “macho orthopods” typically miss. One wonders if looking at orthopaedics specifically might shed light on this.

    1. Yves Smith Post author

      Having seen orthopedists as soon as I could walk, I don’t have a high opinion of them. My experience with them is that the overwhelming majority love to do carpentry, um, surgery, and if you aren’t messed enough to justify operating, their interest wanes. Plus all they can generally offer is rest, ice compression and elevation (when acute), steroids, or sending you to a physical therapist.

      One of the few good ones I had was a referral from someone that everyone had told needed back surgery. She finally got to this orthopedist, who said, “You don’t need to have an operation provided you do exactly what I say” which was stay six months in bed. He was right. She also did a deal (commercial real estate brokerage) that earned her $3 million in fees (this in the 1990s, when that was even more money than now) with attorneys coming to her in her nightgown.


    I wonder if the answer might lie in the patients instead of the doctors. Yes, it’s a demeaning stereotype that women are “better listeners” than men, but it doesn’t change the fact that a lot of people come into social situations assuming that (especially in the elderly population). Maybe there’s a mind over matter thing going on, patients getting treated by women assume their female doctors will pay more attention to them, feel better about their chances, and ergo will fare better. Perhaps the results should be broken down into situations where the patient was aware of the gender of their doctor and those where they were not.

  9. blert

    Female doctors, in my direct experience, simply spend more time with me.

    They also listen.

    Certitude is the difference.

    Male doctors rush to judgment — as if they’re on a battlefield conducting triage.

    1. Portia

      I agree, in my experience female doctors approach on a different level. I think they looked at me, not running through a textbook mentally as if I were a simulation.

      I have had a couple of stinkers though, and I thought it had to do with the practice they worked for.

  10. Norb

    I wonder if this study can be interpreted as documenting another trend in crapification. As healthcare in America focuses more directly on profit generation over providing quality health services and outcomes for patients, maybe women are more inclined to resist this trend than their male counterparts and it shows up in their work. Evolutionary biology would tend to support that view.

    The author seems to be trying to point out a positive aspect revealed in the data, but what if the data is revealing the death throws of an institution? What happens to the system when that remaining 4-5% benefit is driven out of the system? A system that selects for aggressive profit maximization will drive out compassion and altruism and all the associated benefits, stress relief and the feeling of connectedness being examples. Fake compassion does not work with sick people, they tend to see through the sham. How do you measure compassion and it’s benefits? The real question is who gets to define what quality of life means and how to resist the pressures of neoliberalism.

    The American healthcare system is a wealth extraction machine where wellbeing is only a secondary byproduct. Just as the prison industrial complex is built and maintained for profit generation, the medical industrial complex is following along the same lines. Treatment plans are more a product of insurance coverage and ability to pay than desire for a healthy citizenry. Across all professions, the tension between pursuing integrity and compromise brought about by crapification is rising. It’s a matter of physical sorting brought about by system requirements in opposition to the morals and value system individuals choose to adopt.

    Like most things in American culture, we have the illusion of health and longevity. Remove the props, and a pretty hard crash will follow. Health should be defined by resiliency, not dependency.

    1. Portia

      you’re right, it is harder for women to devalue life IMNSHO, and their reasons for going into medicine in the first place may be less likely to be for monetary gain, and after having been likely devalued themselves as candidates for medicine, they have developed compassion. Or hardened up, possibly. I hope that that “wealth extraction machine” does not start keeping out people who aren’t in it for the money.

      Homophones. Death throes, not throws.

  11. dbk

    I just read the study. It was based only on hospitalists (general internists), controlled for severity/type of illness (across eight common categories of acute illnesses of elderly patients 65+; mean age~ 80), and found no statistical differences between the severity/types of illnesses treated by males/females. The physician pool was also controlled for age/number of years practicing.

    The authors suggest that women are more likely to practice evidence-based medicine, to receive higher marks on standardized examinations, and to provide more patient-centered care.

    There is one aspect of their findings which seemed interesting: overall, women hospitalists are more likely to be employed by large, non-profit, university-associated teaching hospitals in the Northeast, arguably the best cohort of hospitals in the country. However, even when compared to their male peers within the same hospital, female physicians had better outcomes in terms of mortality and 30-day readmissions.

    Is it possible that women hospitalists are better than males because males if at all possible opt for a specialization? (My understanding is that being a “general internist” is fairly low on the physician prestige totem pole.) This would be analogous to the situation mentioned above by LifelongLib, where 50 years ago women who would be university professors and CEOs today were limited to school teaching and secretarial positions. This was certainly the case for me – my family made it abundantly clear that if I wanted to work, there were only three jobs open to a girl: secretary, nurse, teacher.

    I don’t know. My own recent experience with women dentists/oral surgeons (2, both women) has been that they are very detail-oriented, very well-prepared, very meticulous/careful, and very attentive to what the patient has to say about what they are experiencing.

    I’d be interested to hear what someone who can actually run the numbers/understand the statistics thinks.

    1. PKMKII

      There is one aspect of their findings which seemed interesting: overall, women hospitalists are more likely to be employed by large, non-profit, university-associated teaching hospitals in the Northeast, arguably the best cohort of hospitals in the country.

      I have a relative that used to work at a doctor headhunting firm, and they observed that in rural/exurbs areas of red states, especially in the South, hospitals and clinics expressed a very thinly veiled preference for “traditional” doctors, i.e. white and male (the job hammered home for them just how alive and well racism is in America). Female doctors are drawn to those northeast hospitals because it’s more difficult to find work in much of the rest of the country.

      1. dbk

        (the job hammered home for them just how alive and well racism is in America)

        And not just racism but sexism as well. Not surprising really.

  12. Jay

    Purely anecdotal, but in my experience with women physicians, they asked more questions, appeared to keep an open mind, and asked more and better follow-up questions. They seemed to be following a logic tree, eliminating alternatives, listening closely for obfuscation, leading to a more accurate diagnosis. On the other hand, my experience with male physicians has been that they come into a situation with certain assumptions, ignored details, and gave a sense that they tended to make educated guesses.

  13. Caelan

    I once read a book in the early 90’s called, ‘The Myth of Male Power’…

    Now, while I’m not necessarily suggesting a particular level of credibility to the book, it did raise important points for me then, such as with regard to the differences in how girls and boys are raised and in the sociosexual constructs built around, and expectations placed upon, them.

    Given those kinds of things, and the fact that men still die earlier than women on average, maybe our culture as a whole would do well to take a look at differences like that.

    In the spirit of the butterfly effect and holistic thinking, let’s never underestimate initial conditions, as powerful as they may be, nor in how an infinite multitude of dynamics interplay with and affect each.

    If or when this happens, and possible suggested changes made as a result, it may be that the differences in death rates for hospital patients depending on whether they are treated by male or female doctors, disappears.

    1. Portia

      I think the “myth” happens when we agree. I just saw a statement above that male doctors are “seen as more competent”. I don’t agree with that, but whoever does agree is giving power to the maleness of doctors. My question is, what segment of the population agrees, and if it is a majority, does that make it true simply because of agreement?

      1. Caelan

        From what is understood of its definition, a myth is a widely-held but false belief. Widely-held could mean a majority, but that still doesn’t make a myth true.

        In any case, my point was less about the title of the book and more about the contents; specifically the differences in how males and females are raised: Simply-put, if males are raised ‘rough-and-tumble’, compared with females, then males may be more likely to treat patients ‘rough-and-tumble’, so to speak.

        It may be that simple, and the root or cause of the problem, rather than the symptom, such as this male doctor versus female doctor research finding.

  14. Ernesto Lyon

    Perhaps women doctors are able to attract high quality mates and prefer the option of a family life with less devotion to career advancement?

    A woman who developed her mothering skills would likely have some bedside manner skills that might come less easily to an equally qualified man.

    The question remains: how much should employers hedge on developing women’s careers when they are likely to leave to raise a family? Is not the problem better framed as a ‘family rights’ issue than a women’s issue?

  15. Beach Populist

    My urologist, gastro, orthopedist, and audiologist are all women and I could not be happier with the treatment I get. Have had a few good male doctors over the years, but now find myself looking specifically for female MD’s when necessary.

    1. Caelan

      Maybe over time, men will stay at home with the kids, while the women work the hospitals and clinics and bring home the bacon. ‘u^

  16. Michael

    As Yves notes, the simplest explanation suffices. Women have to work twice as hard for half the recognition. So they’ll be more competent on average at every level of practice.

  17. MS

    After looking through the comments and reading the study, I would hope everyone would take a step back and really question the study’s real value. So many commenters are listing anecdotal or personal experience as evidence to confirm the validity of this study. While such observations do have value, I would hope that readers recognize that when a study reduces commentary to anecdotes and circular logic instead of research citations and hard fact, the study deserves far more than cursory scrutiny.

    What we really need to consider is how similar the premise of this study is to a hypothetical one that might find that white docors are better than black doctors, or Asian doctors have better outcomes than Hispanic. We should also ask ourselves: if the study would have come out differently, with men getting better results than women, would we view it with a more critical lens? It is my opinion, gender is not and should not be a good indicia of anything except one’s ability to give birth, and any study that claims to discover otherwise deserves a much higher level of scrutiny than has been given either by NC or Gaius or the medical community if they accept the conclusions of this study so easily.

    1. Yves Smith Post author

      The study was well controlled. It’s a solid, large-scale study.

      As I said at the top, I don’t like focusing on gender as a differentiator. However, you ignored the comments re how women are tracked into less prestigious sub-specialities, and being a general intern (as opposed to a specialist) is one. You see this sort of bias in tons of other fields. For instance, on Wall Street, women wind up going more into areas like muni finance and (ironically, back in the day) mortgage finance which were less well paid and less competitive. In finance, you see virtually no women in private equity or hedge funds, which are at the apex in terms of pay and power, save at most some junior women in sales roles (less macho and less well paid than doing deals). This is pervasive and could go a long way towards explaining the results.

  18. Dr Duh

    My personal experience is that women are not ‘tracked into less prestigious sub-specialties’, but rather self select into lifestyle specialties. For example Dermatology, which is extremely competitive and extremely lucrative (on the medicine scale, not business) is extremely female dominated with 62% female residents. Other female dominated ‘lifestyle’ residencies include Endocrinology, Rheumatology, Allergy and Immunology, Preventative Medicine, Geriatrics and Pathology. These are the specialties that almost never get called into the hospital in the middle of the night.

    Women are also over-represented in potentially hard working ‘gendered’ residencies like Pediatrics (72%) and OB-Gyn (82%). Though these have reached a tipping point where men who match into them are outliers. The residencies that men dominate (>75%) tend to be the very highly paid, extremely poor quality of life specialties like Neurosurgery, Vascular Surgery, Orthopedic Surgery, Cardiology and Thoracic surgery, as well as the male gendered specialty of urology. (Source AAMC Physician Specialty Databook 2012)

    You should read the actual paper rather than the press release; this will save you from repeating the flacks’ attempts to oversell the data, e.g., instead of focusing on relative risk (4-5%) which invariably maximizes the magnitude of the study finding you’d note that the difference in absolute risk is relatively small (~0.5%). While the difference in relative risk might be relevant in a macro/policy setting, from the individual patient standpoint it’s the difference in absolute risk that matters, or in this case doesn’t matter, since the difference is clinically trivial.

    That said, the findings are remarkably durable across virtually all of the variables they corrected for. The authors were very thorough in attempting to correct and test for cofounders. I think it’s very possible the effects are real. I would be cautious.

    First because this all depends on correcting for severity of patient illness. I am intensely skeptical of the ability of models to account for disease severity. I’m reminded of a professor’s aside that despite all the attempts by models to account for comorbidities, that the one guaranteed way to improve your ‘batting average’ was to fire your four sickest patients. Which is to say that the models could never account for how badly the outliers would do. Keep in mind that all of these data are based on administrative claims data, not actual clinical data. In other words, if patient A and B both come in with pneumonia and have hypertension, diabetes, hypercholesterolemia, anemia, obesity, depression, tobacco abuse and glaucoma, both patients have it in their admission note, but patient A is coded (billed) for everything, while patient B is only coded as having diabetes, hypertension and tobacco abuse because that’s what’s clinically relevant, i.e. being treated, then they will look like different patients in different risk strata.

    Why might claims reporting differ between the two groups? Men see 37% more patients (180.4 vs 131.9 hospitalizations per year per the paper), perhaps part of how they achieve these volumes (in addition to working longer hours, which is proven) is by only documenting the major items, since it is volume that drives reimbursement. Alternatively, maybe it’s the fact that large institutions and teaching hospitals, both of which women are disproportionately likely to work in, have more complete roll outs of electronic medical records, which are the tools par excellance for capturing comorbidities.

    Maybe the finding that women doctors in primary care adhere more closely to guidelines is generalize-able and that explains the difference. Or maybe they get more out of their teams (though nurses tend to mistreat female docs). Or maybe men are so focused on volume they do 0.5% worse. (Which on a day to day basis is probably invisible) Or women feel they’re so under the microscope that they dot every i and cross every t and that yields an extra 0.5%. Or maybe it’s referring pattern of sicker patients to male doctors or female doctors transferring care to the ICU doctors (more frequently male) sooner. It’s hard to tell. The paper’s supplemental tables make it look like they ran their models on the entire data set and attempted to correct for each factor, rather than running the model on comparable subsets of male and female physicians. I assume this is because they wouldn’t have had big enough samples to generate such pretty P values.

    I’m a bit suspicious that the authors have an axe to grind as evidenced by their tone in the introduction. The consistency of the the p<0.001 across so many groups makes me even more distrustful. I find it odd that alone among all their data, e table 2, which compares the baseline characteristics of male and female physicians, doesn't calculate p values. Typically that's considered relevant to point out the significant differences between the two groups. I'm not a professional statistician and I would defer to a pro, but I'm curious about their decision to use multivariable linear probability vs logistic regression. I caught the distinct whiff of hand waving.

    In the end, I'm willing to consider this single observational study because it does echo results from other domains, specifically performance on standardized exams vs academic performance. Typically men outperform on exams where speed is at a premium, while women outperform academically where conscientiousness and working through a problem completely is rewarded. Perhaps hospitalist medicine is better served by this cognitive model.

    1. Scalpel-6

      Great commentary – was going to post my own but you covered all of my thoughts and more, with more thoroughness I would have had the energy for at this stage in my training…

      I would also like to point out that while JAMA has a very prestigious reputation both among medical professionals and the lay public alike, it (like many other high-impact medical and basic sciences journals – NEJM, Cell, Science, Nature, etc) is highly prone towards publishing articles that they anticipate will be hotly debated and – most importantly – frequently cited. This, in turn, drives up the journal’s calculated impact factor – a number that has long been used as a proxy of a journal’s quality, even though the figure itself is largely meaningless and highly prone to deliberate and artificial inflation.

      This article, with a title and content ripe for viral dissemination via social media and websites such as this, invites plenty of attention and will most certainly nucleate a healthy series of rebuttals and commentaries in other peer-reviewed journals. This in turn will drive up JAMA’s impact factor, which time and time again has proven to be a higher priority of theirs than methodological rigor…

  19. Evie

    Perhaps, given that many men and women, unconsciously or otherwise, have more respect for men’s expertise than women’s, the advice of female doctors is less likely to be followed by patient and nurse alike. In this model, we posit that male and female doctoring is not distinguishable, that doctoring is hugely flawed, and that not following bad medical advice is a means to extend one’s life. So, patients might fare best in the hospital when their doctors are female, merely because they don’t listen to a word female doctors say.

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