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A study from the US has just come out which shows that women are less likely to survive a heart attack if their doctor is a man. The study of over 580,000 myocardial infarction patients showed that women were 1.5% more likely to die if their physician was male; it also found that women were more likely to survive in hospitals where there was a higher proportion of female doctors.
“These results suggest a reason why gender inequality in heart attack mortality persists: most physicians are male, and male physicians appear to have trouble treating female patients,” the authors write.
The authors rightly keep the focus of their study tightly on cardiovascular events. But are there any data out there to support a more general hypothesis that mortality rates may be lower when the treating physician is a woman?
Last year, a Canadian study looked at postoperative outcomes according to the gender of the surgeon involved. The retrospective study of over 100,000 patients undergoing one of 25 different types of surgical interventions found that after matching for age, comorbidity, gender and other possible confounders, fewer patients treated by female surgeons died, were readmitted to hospital or had complications.
The differences were small, but statistically significant, the authors said. They speculated that the female surgeons’ delivery of care might be “more congruent with guidelines, more patient-centred, and involves superior communication”.
Another study published last year compared hospital mortality and readmission rates for patients over 65, according to the gender of the treating doctor. This study, which looked at over 1.5 million hospitalisations, found lower 30-day mortality and readmission rates when the treating doctor was female. Again, the differences were not huge, but they were statistically significant, and the association was consistent across a number of conditions and severity of illness. The authors noted that “data from other industries suggest that men may be less deliberate in their approach to solving complex problems”.
And a meta-analysis of 64 studies looking at physician empathy found that patients were much more likely to describe female doctors as empathetic than male doctors. In an opinion piece, one of the authors makes the point that empathy is needed to be a good doctor.
“Unfriendly doctors are less likely to get enough information from patients to make the right diagnoses, or prescribe the right treatments,” writes Jeremy Howick of the University of Oxford. “One study even showed that unempathetic doctors could cause harm by scaring patients away from medical care when they need it.”
So there you have it. Some of the more recent studies on the subject suggest that women may, on average, make for slightly better doctors than men, in terms of mortality and hospitalisation outcomes. But they are not necessarily getting remunerated for it: female doctors in Australia earn on average around 20% less than their male colleagues, after adjusting for hours worked.
In 2015, vascular surgeon Dr Gabrielle McMullin unleashed a storm of controversy when she said in an ABC interview that female trainees approached for sex by senior colleagues should “comply with the request” if they wanted a career. When a female surgical trainee complains about sexual harassment, she said, “you can be sure they will never be appointed to a major hospital”.
The outcry over her comments sparked a mini “MeToo” moment in Australian medicine and led to the commissioning of a damning report into sexual harassment from Royal Australasian College of Surgeons (RACS). The report contained multiple reports of female doctors expected to provide sexual favours in return for tutorship, along with outrageous stories of discrimination, including one female surgeon who was told she would only be considered for a job if she “got her tubes tied”.
The report recommended a mandatory training module for surgeons, Operating With Respect. But according to the RACS’s own figures, by late last year only 60% of surgeons had completed the course, with the figure dropping to only about half of surgeons in NSW.
Three years on, has anything changed? Perhaps not, at least not in surgery, according to a new study presented this month at the RACS Congress in Sydney. The study is authored by Sarah McLain, a final year medical student, who says there remains a “hidden curriculum” holding women back in surgery. Although women now make up well over 50% of medical graduates, only 12% of surgeons are female, with just 4% of orthopaedic surgeons are women.
Unlike the male students, female med students interested in pursuing a career in surgery are routinely asked how old they are, whether they are married and whether they are planning to have children.
“Being a woman means you might have children and you are therefore perceived as being less committed. You’re told surgery is hard or competitive, with the insinuation that you’re not competitive enough,” she told Fairfax Media.
Her study found a lack of women in leadership roles in medical schools, with only 20% of deans and 5% of heads of surgery at medical schools.
“You can’t underestimate the importance of positive female faculty surgical role models,” Ms McLain said.
Of course, gender discrimination and disparities are by no means limited to surgery. Female doctors are considerably less likely to become specialists than men, and even when they do, they earn substantially less than their male peers. The pay gap between full-time male and female medical specialists stands at 33.6%, with a 24.7% gap between male and female GPs.
Around 63% of graduates from Australian medical schools were women in 2015, and at the beginning of their career their earnings don’t differ from their male colleagues. But as their career progress, a gap appears and then continues to widen. A report from Level Medicine says the reasons for this are complex and include more women in lower paid specialities, less success in negotiating remuneration, and more women taking time off to raise a family.
But these factors do not explain away all of the disparity in earnings, the report says. Around a quarter to half of the pay gap cannot be attributed to hours worked, career interruptions or to employment type, it notes. The rest of it is more to do with systemic discrimination, which includes lack of leadership on pay equity from the colleges, discrimination against women in the more highly paid specialties such as surgery, a lack of female leadership roles and a lack of flexible training and working.
But sexual harassment and pay disparity are not the only issues facing women in medicine. There is good evidence that female doctors are more likely to be affected by burnout than their male colleagues. One theory is that this is due to societal expectations for women to show more empathy than men. In a highly stressful, life-or-death environment like medicine, this can quickly translate into compassion fatigue and put an intolerable stress on female doctors’ mental health. A disturbing study found that while the suicide rate of male doctors was about 40% higher than that of men in the general population, the rate for female doctors was 130% higher than in other women.
Clearly, there is much more to be done before the medical profession can be truly said to be female-friendly.
Until the turn of this century, there was little sense in Western medicine that gender mattered. Outside the niche of female reproductive medicine, the male body was the universal model for anatomy studies.
Clinical trials mainly involved males and the results became the evidence base for the diagnosis and treatment of both genders. Medication dosages were typically adjusted for patient size and women were simply “small men”.
Medical academia has also been male-centred, with teachers, professors and researchers being mostly male. Twenty-five years ago, most college boards representing medical specialities around the world were almost exclusively male.
But in the last 20 years, mainstream medical research has begun to seriously explore gender differences and bias in academic and clinical medicine. This explicit recognition of gender — along with factors such as ethnicity and socioeconomic status — helped determine how healthy all people’s lives are likely to be.
In 2008, the World Health Organisation issued guidelines on “teaching gender competence”. This is the capacity for health professionals to identify where gender-based differences are significant, and how to ensure more equitable outcomes.
Gendered medicine is not only about women. It is about identifying differences in clinical care and ensuring the best health care is provided for all. It is also about ensuring equity of health care access, and about gender equity in the composition and roles in the profession.
Does gender matter?
Gender is not the same as sex, which is about biological and physical male-female differences. Gender relates to the social and cultural behaviours we attach to the biological aspects of sex; it is not binary and exists on a spectrum.
In medicine, gender impacts how, when and why a person accesses medical care, and the outcomes of that access. For instance, women seeing their doctor for chronic pain often don’t feel adequately listened to or supported.
Less well known is that two-thirds of the blind people in the world are women, even when the data is adjusted for the fact women live longer. And as an example of sociological differences that need recognising, women who present with an eye socket fracture, a ruptured eyeball or eye bruise are at risk of dying, not from the injury, but from a further assault by a perpetrator of family violence.
Improving the evidence
Clinical trials are the bedrock of medical research and evidence building. Until relatively recently, they were mainly conducted with males for a number of reasons, including availability to participate and concerns about the impact on women’s reproductive health, or the impact of menstrual cycles on the trials.
Restricting difference also makes trials cheaper by reducing the required sample size (even though it leads to inaccuracies for various important subgroups).
Women were excluded because they are different, but the results were applied to them because they are nearly the same. And when women and men are included in trials, the results are usually not published separated by sex, so the findings may be inaccurate for all participants.
Even in pre-clinical research using animals, female animals have been excluded to make management and costs simpler, and reduce measurement variation.
As a result, large scale clinical trials have yielded findings based on particular population groups. For example, a 1988 study into the use of aspirin to lower the risk of heart attack was based on a six-year trial of 22,000 men.
But change is afoot in trial design. Australia’s largest medical research grant body, the National Health & Medical Research Council, for example, has introduced guidelines that require applicants to address gender equity among research participants.
What are the next steps?
We need data from clinical trials and population data that is sorted by gender, so knowledge bases can be gradually improved. Generalisations about gender can be both useful and problematic, so careful analysis is needed.
We must account for gender in all medical training, and clinical practice. This should apply to not only disciplines that relate to sex hormones such as gynaecology, but also for example orthopaedics and ophthalmology.
We need the profession itself to take the lead in encompassing gender diversity in our community. Following the lead of non-medical groups such as the Australian Institute of Company Directors, the medical profession needs to introduce targets for diverse representation on all professional decision-making bodies.
Sarah, an Australian medical student in her final year, told me the biological perspective is taught well, but the psychological and social “not so much”.
There are broader social and cultural factors that might affect the way a male patient presents versus a female.
Medical training on diversity also needs to include people who are transgender or who identify as non-gender conforming. As Sarah said:
We talk about inequalities in terms of males and females, but gender diversity isn’t mentioned at all. I shudder to think of the barriers and obstacles you might face in training if you were transgender or non-gender conforming. I haven’t heard anyone raise that.