Are you shocked by this news? Me, not so much. But, hats off to the Harvard research team and their new approach to tackling gender inequality in medicine by getting back to the basics: Let the evidence speak for itself. And, it does (to a certain extent).
Since all most people care about is who lives and dies or patient outcomes, why not study if the physician’s gender plays a critical role in the all-important realm of survival?
Ok, so for full disclosure, this article brings me joy. For so many reasons. On so many levels. Mainly, for the chuckle and laughter I already have enjoyed in response to some reactionary, knee-jerk posts on social media and in person that range from dismissing the publication as another feminist attack that would never be granted in the reverse. Hmmm… do I detect some false equivalence? Or, some hyped up over-intellectualized rants that certainly have intermittent merit, but turn out upon review of these latest findings to be readily accounted for and properly addressed in the data collection and analysis.
If not convinced, then I advise you merely to read the actual study and its measured guidance for interpretation.
The reality of the work, like most studies, contributes to advancing the discussion but is certainly no panacea. The questions abound as to whether outcomes can truly be quantifiable and how accurately and appropriately they can be attributed to a specific health care provider.
So, what did the investigators do and how does being a male or female physician possibly inform patient outcome?
First, they recognized much of the work already published on the topic of gender inequality in medicine does not address outcomes, but rather reveals differing practice patterns between male and female physicians, that females provide higher-quality care, perform the same or better on standardized testing, are more likely to adhere to clinical guidelines as well as offer more preventive measures, follow evidence-based medicine, employ a more patient-centered communication style, to name a few. (1)
This academic crew from Harvard’s School of Public Health sought to explore whether this favorably or unfavorably impacted patient outcomes. They determined it did, the ‘why’ will necessitate further study.
Their work just published in JAMA Internal Medicine concluded elderly hospitalized patients cared for by female doctors (specifically internists in the hospitalist role) endured lower 30-day mortality and readmission rates than their male counterparts. The research utilized Medicare beneficiaries 65 years or older hospitalized in acute care settings from January 1, 2011 to December 31, 2014. This sample included those admitted on a non-elective basis with their analysis restricted to 8 common conditions within that practice field: sepsis, pneumonia, congestive heart failure, chronic obstructive pulmonary disease, urinary tract infection, acute renal failure, arrhythmia, and gastrointestinal bleeding.
Adjustments of confounding factors like only making data comparisons within the same hospital or capturing and identifying the greatest influence of the lead physician, being on average 51.1% of the Medicare spending throughout the stay and so forth were made to garner the most significant knowledge and means of legitimate and precise evaluation. Restricting the specialty choice to only internists who are hospitalists achieves this as well.
Using the mode of Medicare Part B spending as use of care to decipher the most involved physician in that particular hospital stay is an imperfect, yet still valuable avenue. Since hospitalized patients routinely encounter multiple care givers, it seems they isolated the lead female or male physician to study by those who contributed the most in expenditure during the hospital stay. This might not be accurate all of the time. Regardless, it was a uniform and systematic approach that reflects the provider likely to have been the majority influence of the stay and was deemed not to affect their findings once factoring in their statistical analyses. Additionally, they did account for observed differences between male and female physicians assessing length of stay, patient volume and discharge location of the patients (e.g. home, hospice, long-term skilled facility, other).
What prompted them to explore the issue?
This is clearly outlined in the journal article’s introduction:
“Female physicians now account for approximately one-third of the US physician workforce and comprise half of all US medical school graduates. Despite evidence suggesting that female physicians may provide higher-quality care, some have argued that career interruptions for childrearing, higher rates of part-time employment, and greater tradeoffs between home and work responsibilities may compromise the quality of care provided by female physicians and justify higher salaries among male physicians. Therefore, empirical evidence on whether patient outcomes differ between male and female physicians is warranted.”
What claims do they actually make about the impact of their results?
“We found that elderly patients receiving inpatient care from female internists had 30-day lower mortality and readmission rates compared with patients cared for by male internists. This association was consistent across a variety of conditions and across patients’ severity of illness. Our findings…are consistent with results from prior studies of process measures of quality. Although the difference in patient mortality between male and female physicians was modest, an observed effect size of 0.43-percentage point difference or a relative risk reduction of 4% in mortality is arguably a clinically meaningful difference…given that there are more than 10 million Medicare hospitalizations due to medical conditions in the United States annually and assuming that the association between sex and mortality is causal, we estimate that approximately 32,000 fewer patients would die if male physicians could achieve the same outcomes as female physicians every year.”
If one extrapolates further to those outside of the Medicare system, then the impact considerably widens. A seemingly low percentage at quick glance on this page manages to translate in this circumstance to countless human lives. We shouldn’t be so quick to disregard that very valid fact.
Take Home message…
Though the study result reflects a small percentage, it is not an inconsequential conclusion and manages to build on an expanding body of existing research. Examining further as to why there are differences in practice patterns between the genders— especially if there is a potential for positive patient outcome— could have real clinical relevance and implications. Yes, more investigation is warranted. Generalizing to other specialties based on this study is premature as echoed by the authors, but exploring it is certainly worthwhile.
The accompanying editorial written by the JAMA Internal Medicine editor and editorial fellow entitled “Women in Medicine and Patient Outcomes: Equal Rights for Better Work?” adds “these findings that female internists provide higher quality care for hospitalized patients yet are promoted, supported and paid less than male peers in the academic setting should push us to create systems that promote equity in start-up packages, career advancement, and remuneration for physicians. Such equity promises to result in better professional fulfillment for all physicians as well as improved patient satisfaction and outcomes.”
Food for thought…
This discovery won’t solve the complexities of gender inequality in medicine, but it does serve to be a necessary catalyst that could expand the discussion, deepen understanding and stimulate efforts to learn more, improve it, health care delivery and patient outcomes to boot. Win-win.
(1) Tsugawa et al. Comparison of Hospital Mortality and Readmission Rates for Medicare Patients Treated by Male vs Female Physicians. JAMA Internal Medicine. 12/19/16.