In 2015, US surgical resident Heather Logghe, inspired by a hashtag from a female engineer, tweeted ‘#ILookLikeASurgeon”. Within weeks, her post had snowballed into an international social media movement, as thousands of women surgeons posted selfies to challenge gender stereotypes, highlight inequalities and celebrate the changing face of the profession¹. 

In the space of two years, the hashtag had nearly one billion impressions, attracted mainstream media coverage and even inspired a cover of The New Yorker² – gaining momentum as women all over the world recreated the iconic image of an all-woman surgical huddle³. 

In 2023, the publication of a study demonstrating that patients of female surgeons experienced better outcomes⁴ took the media by storm, with coverage in numerous outlets. It provoked strong reactions, ranging from the incredulous to the outright misogynistic, on the same social media platforms where women surgeons had previously been celebrated. This was not the first time that data had been published with this conclusion. In the past decade, numerous similar studies have been published, demonstrating that women surgeons appear to achieve better surgical outcomes than men and calling for better understanding this phenomenon, which might help improve performance for surgeons of all genders and strengthen the profession as a whole.

Gender bias: the problem

The professionalisation and status of modern western medicine can be traced back to the Enlightenment: a time when rational thought and observation were established as the tenets of ‘good science’ that we still value today. Enlightenment influencers were almost exclusively white, European men, whose seemingly neutral categorisations of race and sex further validated their authority and the image of a doctor subsequently reflected this⁵. Moving into the late 19th century, anaesthesia and antibiotics enabled surgeons to gain prestige by satisfying Victorians’ eagerness for progressive and daring heroes; but in a society where women were considered the weaker sex, and far too delicate for the bravado and gore of the operating theatre, surgery (and medicine in general) was very much cemented as a male pursuit. Some surgeons themselves aimed to exclude women from their ranks, as described in a recent issue of Surgeons’ News⁶.

The legacy of the stereotype of the male surgeon remains to this day. Surgeons, and healthcare professionals in general, have been demonstrated to show both explicit and implicit gender bias⁷, such that they associate men with surgery and women with family medicine; or men with careers and women with family. Patients tend to view female surgeons as warmer but male surgeons as more competent⁸. These stereotypes are not just outdated beliefs, they continue to cause harm. A study of surgical residents demonstrated that both men and women surgical residents perceived those around them to expect men to be better surgeons than women and that, among women residents, that perception was associated with worse mental health⁹. In addition, women doctors have been found to receive fewer resources and have less control over their workload and schedules¹⁰. 

One of the inherent challenges women surgeons face is navigating the double bind. Whereas societal expectations of behaviour for leaders are aligned with our expectations of men (assertiveness, confidence, being direct, etc.), they are at odds with our expectations of women (kindness, nurturing, caring, etc.). Consequently, when women surgeons act as leaders they are often disparaged, even though their men colleagues are rewarded for that same behaviour. All of this contributes to the findings of a systematic review that showed inequity between genders in terms of support, opportunities and harassment, with mothers being disproportionately affected¹¹. That all this persists, despite data repeatedly demonstrating the benefits of gender diversity for organisations (including the skills women leaders bring), is a testament to how tenaciously we hold on to gender-stereotypical views^12,13.

Surgical outcomes and gender

As we noted earlier, multiple studies demonstrate that the patients of female physicians – and specifically female surgeons – have better outcomes, on average, than the patients of men physicians^14,15,16. The 2023 study mentioned above⁴ analysed data from more than one million patients undergoing common procedures in Canada. The authors found that patients of female surgeons for elective cases had lower readmission rates and 25% lower 90-day mortality rates, compared with patients of male surgeons. There was no difference in outcomes by surgeon sex for emergency cases. Although these data are correlational, the huge number of patients allowed for a multitude of variables, including numerous and interacting comorbidities, to be accounted for. A follow-up study to this demonstrated lower healthcare costs (~$6,000 less over the course of a year) among patients of female surgeons¹⁷. 

Rather than sparking conversations about why this might be the case, and identifying ways in which all surgeons can potentially deliver the same quality of outcomes as women, much of the reaction to the data has focused on accusations of flaws in study design or looking for ways to discredit these large-scale controlled studies. A few weeks after the 2023 study was published, women surgeons were yet again in the headlines when a Working Party in Sexual Misconduct in Surgery found nearly one in three UK female surgeons, who responded to its survey, had been sexually assaulted at work¹⁸, yet few put two and two together: despite clearly established challenges and barriers in surgery, women are more than holding their own.

What can we learn from the evidence?

The finding that differences in patient outcomes by surgeon sex are more notable in elective cases suggests surgical judgment (including patient selection), communication skills and surgical planning may be approached differently by men and women. This would be consistent with the literature, which for several decades has documented differences in how men and women physicians practice medicine. For example, female physicians spend more time with patients and are more likely to inquire about psychosocial factors that affect health, engage in partnership-building, follow care guidelines, perform preventative care and consult other specialists when appropriate^19,20,21,22. In the emergency setting, there is less time to consider these factors and the equivalent outcomes suggest there is no significant difference in technical skill by sex.

All this suggests that, regardless of a surgeon’s sex, there is likely a benefit to being diligent about the care we provide: following guidelines, making sure we have all relevant information and making thoughtful plans that take into account the needs of individual patients. 

Future challenges

Alongside changes in individual surgeons’ behaviour, what can be done at an organisational level to counter entrenched gender stereotypes and drive surgical excellence? Leaders must learn about gender dynamics – including the additional labour women surgeons often have to give to get the support they need for their patients²³ – to better support women surgeons. In addition, they should track outcomes in hiring, retaining and promoting surgeons to assess and address disparities. Standardising interviews, implementing equitable resource allocation, and updating policies and procedures related to compensation and leadership can reduce bias and lessen the burden on the individual to push against inequities. 

Simultaneously, we must recognise that the status quo in surgery is reflective of gender inequity at societal level, and we must also look beyond healthcare environments to recognise and address biases and stereotypes that may be held by patients and other parties.

Note: Throughout this article, the terms ‘men’ and ‘women’ are used to refer to people in general. When discussing specific research studies, we use ‘male’ and ‘female’ if the study reports on sex, and ‘men’ and ‘women’ if the study reports on gender.

References

1. Logghe H, Jones C, McCoubrey A. #ILookLikeASurgeon: embracing diversity to improve patient outcomes. BMJ. 2017;2017(359):j4653. 

2. Cover Story: Malika Favre’s “Operating Theatre” | The New Yorker [Internet]. [cited 2025 Feb 1]. Available from: https://www.newyorker.com/culture/culture-desk/cover-story-2017-04-03

3. Female surgeons around the world recreate magazine cover to fight gender stereotypes | The Independent | The Independent [Internet]. [cited 2025 Jan 30]. Available from: https://www.independent.co.uk/news/world/americas/female-surgeons-new-yorker-cover-recreate-gender-stereotypes-medicine-a7680726.html

4. Wallis CJD, Jerath A, Aminoltejari K, Kaneshwaran K, Salles A, Coburn N, et al. Surgeon Sex and Long-Term Postoperative Outcomes Among Patients Undergoing Common Surgeries. JAMA Surg. 2023 Nov 1;158(11):1185–94. 

5. Schiebinger L. The Anatomy of Difference: Race and Sex in Eighteenth-Century Science. Eighteenth-Century Stud. 1990;23(4):387–405. 

6. Cahif J. A fresh look at diversity: Interpreting gender inequality in our heritage. Surgeons’ News. (June 2024):24–7. 

7. Salles A, Awad M, Goldin L, Krus K, Lee JV, Schwabe MT, et al. Estimating Implicit and Explicit Gender Bias Among Health Care Professionals and Surgeons. JAMA Netw Open. 2019;2(7):e196545. 

8. Ashton-James CE, Tybur JM, Grießer V, Costa D. Stereotypes about surgeon warmth and competence: The role of surgeon gender. PloS One. 2019;14(2):e0211890. 

9. Salles A, Mueller CM, Cohen GL. Exploring the Relationship Between Stereotype Perception and Residents’ Well-Being. J Am Coll Surg. 2016 Jan;222(1):52–8. 

10. Lyubarova R, Salman L, Rittenberg E. Gender Differences in Physician Burnout: Driving Factors and Potential Solutions. Perm J. 2023 Jun 15;27(2):130–6. 

11. Lim WH, Wong C, Jain SR, Ng CH, Tai CH, Devi MK, et al. The unspoken reality of gender bias in surgery: A qualitative systematic review. PLoS One. 2021 Feb 2;16(2):e0246420. 

12. https://www.apa.org [Internet]. [cited 2025 Feb 1]. Women leaders make work better. Here’s the science behind how to promote them. Available from: https://www.apa.org/topics/women-girls/female-leaders-make-work-better

13. Diversity wins: How inclusion matters. McKinsey & Company May 2020 [cited 2025 Feb 1] Available from: https://www.mckinsey.com/~/media/McKinsey/Featured%20Insights/Diversity%20and%20Inclusion/Diversity%20wins%20How%20inclusion%20matters/Diversity-wins-How-inclusion-matters-vF.pdf 

14. Wallis CJ, Ravi B, Coburn N, Nam RK, Detsky AS, Satkunasivam R. Comparison of postoperative outcomes among patients treated by male and female surgeons: a population based matched cohort study. BMJ. 2017 Oct 10;359:j4366. 

15. Tsugawa Y, Jena AB, Orav EJ, Blumenthal DM, Tsai TC, Mehtsun WT, et al. Age and sex of surgeons and mortality of older surgical patients: observational study. BMJ. 2018 Apr 25;361:k1343. 

16. Wallis CJD, Jerath A, Coburn N, Klaassen Z, Luckenbaugh AN, Magee DE, et al. Association of Surgeon-Patient Sex Concordance With Postoperative Outcomes. JAMA Surg. 2022 Feb 1;157(2):146–56. 

17. Wallis CJD, Jerath A, Aminoltejari K, Kaneshwaran K, Salles A, Buntin MB, et al. Surgeon Sex and Health Care Costs for Patients Undergoing Common Surgical Procedures. JAMA Surg. 2024 Feb 1;159(2):151–9. 

18. Sexual harassment, sexual assault and rape by colleagues in the surgical workforce, and how women and men are living different realities: observational study using NHS population-derived weights | British Journal of Surgery | Oxford Academic [Internet]. [cited 2025 Jan 30]. Available from: https://academic.oup.com/bjs/article/110/11/1518/7264733

19. Franks P, Bertakis KD. Physician gender, patient gender, and primary care. J Womens Health 2002. 2003;12(1):73–80. 

20. Hall JA, Irish JT, Roter DL, Ehrlich CM, Miller LH. Gender in medical encounters: an analysis of physician and patient communication in a primary care setting. Health Psychol Off J Div Health Psychol Am Psychol Assoc. 1994 Sep;13(5):384–92. 

21. Roter DL, Hall JA, Aoki Y. Physician gender effects in medical communication: a meta-analytic review. JAMA. 2002 Aug 14;288(6):756–64. 

22. Lurie N, Slater J, McGovern P, Ekstrum J, Quam L, Margolis K. Preventive Care for Women – Does the Sex of the Physician Matter? N Engl J Med. 1993 Aug 12;329(7):478–82. 

23.Cardador MT, Hill PL, Salles A. Unpacking the status-leveling burden for women in male-dominated fields. Adm Sci Q. 67(1).

When JAMA published the studies by Wallis et al. and Blohm et al. in August 2023, demonstrating lower risks of adverse outcomes in Ontarians and Swedes, respectively, when treated by female surgeons, The Times, The Guardian and The Wall Street Journal were among the newspapers covering the story.

The lead authors of the JAMA studies were quoted: Dr Christopher Wallis mentioned that he had already adopted practices from his female colleagues and encouraged male colleagues to be introspective in the light of the findings; Dr My Blohm suggested that the results might relate to surgical technique and risk-taking, at least to some extent. 

Professor Martin Almquist, author of the accompanying JAMA editorial, reflected that the finding that women surgeons might be slower but safer suggests that “the Navy Seal mantra ‘slow is smooth, and smooth is fast’ also applies to surgery”. Women are “more likely to use patient-centered decision-making, more willing to collaborate, and more carefully select patients for surgery”, Professor Almquist noted.

An opinion expressed in both mainstream and social media was that the studies demonstrate association not causation, and that the published differential outcomes between male and female surgeons were due to differential case complexity. Some prominent female surgeons on Twitter, including Orthopaedic Surgeons Roshana Mehdian and Laura Hamilton, were openly critical of this response, taking care to point out that case complexity was one of several variables that had been taken into account in the analysis of study data.

The responses on social media were varied and included some interesting takes, ranging from those fully discrediting both studies to those uncritically cheerleading the results. Several responses from male users of social media suggested female surgeons “might take the easy cases” or “avoid the complex work”; their approach was nicely summarised by one user as the “but men do harder surgery brigade”. ENT Surgeon Laura Dias reflected that if women did take on less complex work and thus had fewer complications, perhaps the saying “a good surgeon knows when to operate, a great surgeon knows when not to” ought to be discussed. Meanwhile, many responses from users of all genders echoed the suggestion from Wallis that this was an opportunity to learn from female surgeons and perhaps add teachable points to the surgical curriculum.

Of course, all these sentiments have been shared before. As one social media user noted, “these papers come out every year”; the same seems to apply to the associated discourse. A previous study from Wallis and colleagues in 2021 met with precisely the same response on social media. And when BMC Health Services Research published a systematic review and meta-analysis in January this year, looking at physician sex and patient outcomes across 35 studies, the same comments appeared: case complexity was not properly considered. Some users were certain the only way to be sure would be a fully blinded, randomised controlled trial (RCT). While it is not uncommon for medics unfamiliar with the value of observational data to call for questionable RCTs, others on social media quickly highlighted that RCTs are not always appropriate and, given the strength of data from large observational studies, we should be taking affirmative action right now to improve patient safety.