The 'best surgeons' don't all look the same

The ‘best surgeons’ don’t all look the same

A major UK news publication has published a long list of the best knee replacement surgeons, made up entirely of white men. Would a similar list be published in Australia? Neela Janakiramanan and Christine Lai, two of just 768 female surgeons in Australia according to 2017 data, respond. 

How do you choose a good surgeon? The Daily Mail have taken it upon themselves to provide a list based on asking other surgeons who they would recommend. They disclaim that this is not a scientific study, but this does not stop them from providing a list of names that their headline claims are the “best knee replacement surgeons.”

To the disappointment of doctors around the world, the recommendations provided are all Caucasian men. While this is a UK newspaper, surgery is one of many industries where the need for a diverse workforce is globally recognised, and one where the few diverse members still feel disenfranchised. It is not hard for us to imagine such a list being equally homogenous in Australia.

According to the Royal Australasian College of Surgeons Workforce Data, there were only 768 female surgeons in 2017. These women represented in very similar proportions to the UK – 12.1% of all surgeons, 27% of paediatric surgeons and 4% of orthopaedic surgeons. The reasons for low female representation in surgery are varied and still being studied, but the reality is that the demographics of the surgical workforce is changing very slowly.

In addition to gender, The British Medical Association Equality Lens data, shows that 32.1% of UK doctors identify as having a non-Caucasian minority cultural background, of which 24.4% have Asian heritage. We don’t have this data for Australia, and as far as we can tell, there is no data collected on other elements of diversity such as religion and sexual orientation. Regardless, we only have to look around to see that increasingly the surgical workforce reflects the diversity we see in broader society every day. Based on this limited data, there should have been at least one female orthopaedic surgeon, and five surgeons of Asian heritage named in The Daily Mail’s list of twenty recommendations, if this list truly represented the surgical workforce.

So we have to ask – should a ‘best of’ list of surgeons be representative, and if so, why wasn’t it? 

Diversity is important to all industries. In the medical profession, diversity is critical because the patients we treat are diverse. We know that good medical care extends beyond the technicalities of performing an operation – it is about assessment of a patient’s specific needs, understanding of their individual circumstances, and providing care that is takes into account the person they are rather than just addressing an arthritic knee as if it is just a biological problem.

Diverse patients require diverse health care providers, especially as medicine has now long moved on from a patriarchal model of care where doctor knows best.

Women are capable surgeons. Although it is galling that this is questioned, female competency in surgery was comprehensively demonstrated in a paper published in the British Medical Journal last year. This study looked at all patients undergoing one of twenty-five procedures in Ontario, Canada, over a period of 9 years – a staggering 104,630 operations performed by 3314 surgeons (774 women, 2540 men). To summarise, this study found that the female surgeons had potentially better outcomes than men, with their patients less likely to die in the month following surgery, and no difference in the rate of complications or readmissions to hospital.

So if women are at least as good at performing surgery than men, if not better, why has a survey of doctors found that their idea of the ‘best’ surgeons is universally male, and a white male at that?

Unconscious bias plays a large role in this. Affinity bias is a tendency to warm to people like yourself, and largely forms the basis of corporate hiring practices that prioritise making sure than an individual is a ‘good fit’.

In medicine, this can happen at multiple points. It can manifest as other doctors, including both surgeons and non-surgeons, and even Directors of Medical Education and Training actively advising women to avoid a career in surgery; it can result from selection processes where the selectors consider whether a candidate is a ‘good fit’ for the profession; it can occur when selections occur for subspecialty training programs where surgeons get extra training to make them experts in a small part of the field (such as knee replacement surgery); it can occur when hospital units, especially large, established, academic units, hire new surgeons, often also based on a ‘good fit’ model.

Even after running the gauntlet of these selection hurdles, woman can continue to be disadvantaged long into their careers as they are less likely to be asked to present at conferences and sit on panels, just as in other industries. Given that conferences are where ‘experts’ are made, this long trajectory of bias means that women are less likely to ever be seen as an ‘expert’.

Confirmation bias then comes into play when doctors are more likely to see and take note of the positive outcomes of a group that they think should be performing well, while being more likely to take note of the negative results of those they think may not perform well.

In surgery, a working paper from Harvard found that referring doctors were likely to stop referring to a female surgeon after a single bad outcome, but not a male surgeon, where a complication is more likely to be put down as ‘bad luck’ rather than deliberate poor care. The addition of halo and cloven foot effects – where other characteristics are related to more or less competence in other unrelated areas –creates a scenario where the ‘best surgeons’ all look the same.

Of course this is done with the idea of preserving merit and not to be discriminatory – which is why it is called unconscious bias.

But we know from multiple industries that the more an organisation believes that merit is the critical determinant of selection, the more likely it is to discriminate against women, because the incumbents are the determinants of merit. Women are also much less likely to put themselves forward due to the hostile sexism they tend to experience when showing male associated traits of leadership such as confidence and assertiveness. The downstream effect is that that the successes of male surgeons are more visible and known.

Good medicine is about more than just the technical skills to perform an operation, therefore it is essential that we have a diverse workforce to service a diverse population.

The surgeons listed by The Daily Mail might be ‘the best’ according to a survey of doctors who are also predominantly male, but they might not be ‘the best’ for any given patient.

The reality is that surgical training in Australia and the UK is highly regulated, and there are very high standards set to ensure a minimum level of skill before training surgeons are allowed to practise. Every orthopaedic surgeon who graduates has been trained to competently perform the technical aspects of a knee replacement, so the factors that then become more important are a little more ephemeral. Do you like the surgeon? Are they kind? Do they communicate well? Do they win your trust? Asking other surgeons who they recommend does not always ensure a good fit for any given patient, especially patients who are female or members of other minority groups.

So it is with great disappointment that we note that The Daily Mail has created a survey which cannot take into account any of these other considerations, and has published a list of individuals that does not reflect in any way the diversity of the modern surgical workforce. We care about this list from across the world, because this is simply another example of why diversity and inclusiveness in the medical profession here will not happen by accident.

We are proud to be a part of the diversity in surgery.

Pictured above: Neela Janakiramanan (L)  and Christine Lai

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