Everything, throughout the history of medicine, from the profession’s origins, to the way drugs are tested and the diagnosis of medical conditions, works on a model where the male body is the default and the female body is ‘the other’. Amazingly, it is still the case now. This is not equality says Dr Sarah Hillman, Academic Clinical Fellow at Warwick Medical School and GP registrar, who wants to see changes in the way that medicine considers women.
Sarah Hillman graduated from medical school in 2004. “I never questioned my ability or eligibility to go to medical school,” she explains. “So, naively, I had never really considered that gender bias existed in medicine. However, as my experience grew, so did my realisation. I now proudly call myself a medical feminist and all I am asking is for women to be treated the same as men.”
What does a doctor look like?
These days, nobody would consider that a woman could not reach the highest tier of medicine, but Dr Hillman describes the moment she discovered her own unconscious gender bias.
“A colleague told me she had attended a conference where the keynote speaker – a well-respected professor – appeared on stage and there were audible whispers and comments when people realised, with surprise, that this professor was a woman,” she explains. “I knew of this professor and it was with embarrassment that I realised that I had also made the assumption that they were a man. I had an unconscious gender bias when it came to thinking about what a senior medical professional looked like.
“It was just 150 years ago that the first seven women enrolled onto a UK medical degree. Their lives were made difficult. They were charged more to attend then the men. They were instructed to find their own lecturers. And at one point, they were obstructed by hundreds of people from entering an anatomy exam.
“These women were known as the Edinburgh Seven and they went on to achieve everything that was expected of them, and more, but they were never allowed to graduate”
“Thankfully the proportion of women represented in the medical profession has changed rapidly since then. Women now make up the majority of doctors in training, and even in traditionally male-orientated specialities such as surgery the proportion of women in training is on the rise. However, there is some way to go and the pipeline shows that we lose many talented women on the way.”
How women became ‘the other’
Unconscious bias is rife in society – not just the medical profession – and it occurs when we use our instinct over objective analysis to make a snap decision.
“I started to think about unconscious bias,” continues Dr Hillman. “If it was affecting the way I consider my colleagues, could it be affecting other things – for instance, could it be affecting the care I give my patients?
“I realised it’s not just a medical HR problem, it goes deeper than that. Society has been sleepwalking into male-orientated medicine.
“Since the days of Hippocrates, the physicians, scientists, philosophers were all men. That meant that the male body became default. The female body became the ‘other’.
“Historically, much of the research around drugs has been done on proportionally more male cells, male animal models and relatively more male participants. There’s an increasing body of evidence to say that female mice have different outcomes to male mice and that would translate to work in humans.
“It's understandable that from a scientific point of view, that people developing drugs would test them on male mice – they are bigger, they don’t have a hormone cycle and so the scientists get much more consistent and reproducible outcomes. But the problem is, human women have hormone cycles and inconsistencies within those cycles. If we don’t use female animal models, how do we know what will happen in human women?
“We then go on to administer drugs in gender-neutral doses despite the obvious size, fat muscle and hormone ratio differences. No wonder, more of my female patients tell me they have reactions to treatments.
“What concerns me is that we have missed an entire stage of the process. Have we dismissed drugs that don’t work for men, but might have worked for women? Are we wrongly prescribing for all women?”
Missing the signs
Another hugely problematic gendered issue is diagnosis of serious conditions. Dr Hillman explains: “In heart attacks, the most common symptom in both men and women is chest pain. But women present with more associated symptom like palpitations or nausea and these associated symptoms might cloud a physician’s judgement.
“We can do a blood test to confirm a heart attack diagnosis which measures the levels of an enzyme released from the heart muscle when it is damaged. Up until recently the threshold level we were using in this test was set too high so we were missing women’s heart attacks. As women’s hearts are smaller – they release less of the enzyme and so women’s heart attacks were not registering in the diagnostic test.
“These biases are leading to misdiagnosis. Women are 50% more likely to have a misdiagnosis following a heart attack then men. Women are less likely to receive the right intervention or the right drugs after heart attack and therefore they are at increased risk of death. Women are dying and we are letting it happen.
“It is time for change in our medical system. We can reimagine it. Rewrite it. This is not men versus women. This is our past versus our future. Let’s stop and listen to women and question what we thought we knew. Women don’t have to be the other anymore.”
Dr Hillman’s Top 5 ways to achieve gender equality in medicine
- Include women in the decision making, from research to policy making to NHS leadership
- Ensure research thinks about gender. Are women represented even if it is at a cellular level? How do you know that gender doesn't play a role in the outcome?
- Teach students about gender inequality, include it in the curriculum. These people are our medical future
- Stop and listen to patients. Question what you thought you knew. In a system that was driven by men for men historically, how much of what we practice now is wrong for women?
- Call yourself out when your unconscious bias becomes fleetingly conscious. It’s an uncomfortable thing to do, but if you start you will realise how often you will make an assumption based on someone's gender.
6 March 2020
Dr Sarah Hillman is an Academic Clinical Fellow at Warwick Medical School and a GP.
Her main research interests are women's health and genetics in primary care. Her initial focus is on how polycystic ovarian syndrome is managed in primary care.
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