"Why Can’t A Woman Be [ treated ] More Like A Man?"
"Why Can't a Woman Be More Like A Man?"The question posed by the “My Fair Lady” lyrics might be revised by some to “why can’t a woman be treated more like a man?” The consequences of the issue of gender inequality is analogized as like cancer detection in an article “Early Detection of Differential Treatment” by Alison Jost in the November 3, 2006 issue of Bioethics Forum. The article describes the author’s experience with her new dermatologist (a male dermatologist) and her suspicions that she received differential treatment (in a negative sense) with respect to what a man might have received. Although she reminds us of other areas of differential treatment of women's health and life,she is worried that this unequal treatment by physicians may be, at times, to the detriment of the woman’s health. The author seems to be concerned that some women would not early recognize the inequality and therefore not act on it, thus leading, like the need for early cancer detection, to their medical harm.
There are some questions that arise from this article. One is: is the concern about differential treatment realistic? There has been published commentary about the missed diagnosis and therefore missed treatment of women who have significant coronary artery disease. This might support the concern. Another question is whether women physicians also provide differential treatment to women patients and, if so, what is the difference regarding their behavior or their attention to the needs of woman vs men? If the differential treatment is real,what is the motivation of the physician? Any help on these questions? ..Maurice.
posted by Maurice Bernstein, M.D. @ 10:59:00 PM
8 comments
8 Comments:
We have all been guilty of differential treatment at one time or another (probably more often than we would like to admit). We make assumptions about everyone we meet, every situation that we encounter. It is part of the way that we sift through the incredible amount of information that the world throws our way. I think that physicians have to combat this behavior in a special way because when taking a history, it is easy to decide what the diagnosis will be and what course of action should be taken before the patient has actually provided any information. Physicians are notorious for interrupting patients after letting the patient speak for less than 30 seconds.
Differential diagnosis is not limited to gender differences; it spans all differences and similarities based on color, culture, socio-economic status, height, weight, age, etc., etc., etc. EVERY PRACTITIONER (female and male alike) is at risk for arriving at a differential diagnosis. In fact, I think that without a conscious effort to avoid such diagnoses based on assumption, prejudice, and preconceived ideas, it wold be easy to slip into such behavior. These assumptions let us be lazier clinicians because these limit the amount of effort that one must give to each patient. When we make sweeping assumptions about a patient, her values, her needs, her concerns, and her diagnosis, we risk missing the point all together.
Alyssa, I think the author meant by "differential treatment" simply the approach, communication, pre-judgment and other intellectual behavior by the physician to the patient may be different between the two genders and perhaps, as viewed by the patient, a more unpleasant and unsatisfying overall behavior or less adequate clinical attention to women than to men. The use of the term "differential diagnosis" really deals with the series of diagnostic possibilites as a physician considers the cluster of sympotoms, physical findings and lab tests. It is true that a physician's differential diagnosis of a patient may be altered because the patient is a woman. This may be based on statistical differences regarding certain diseases comparing the incidence between the two genders. On the other hand, the differential diagnosis might be affected by undocumented theories which are based on male stereotypic views of women as compared with men. This then would be an example of how pre-judgment could erroneously alter the differential diagnosis and thus lead to "differential treatment" both in the doctor-patient relationship but also in the clinical treatment plan. Again, using the documented example of the way women have been looked upon with their chest pain symptoms, there has been views by physicians that women tend to have neurotic based chest pain symptoms and consequently their subsequent cardiac workup may be inadequate and the patient ends up being treated for neurosis rather than the underlying angina due to coronary artery disease. And this is the harm that could arise from "differential treatment". ..Maurice.
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Alyssa, I see you deleted your comment which extends the discussion of "differential treatment" to differences beyond that of gender to that of racial and other. I think that is a good topic to put up as a new posting. If you give me permission, I can put up what you had written but removed or you can write me e-mail a revised commentary and I will put it up myself as a new posting from you. Please write me: DoktorMo@aol.com ..Maurice.
As an example of "differential treatment" which is gender based, here is a study from 1997 in the journal Soc Sci Med. 1997 Sep;45(5):711-22, the full abstract of which is available on
PubMed and titled:
Gender differences in medical treatment: the case of physician-prescribed activity restrictions.
written by Safran DG, Rogers WH., Tarlov AR, McHorney CA, and Ware JE Jr. from Health Institute, New England Medical Center, Boston. I have reproduced part of the full abstract below.
A growing scientific literature highlights concern about the influence of social bias in medical care. Differential treatment of male and female patients has been among the documented concerns. Yet, little is known about the extent to which differential treatment of male and female patients reflects the influence of social bias or of more acceptable factors, such as different patient preferences or different anticipated outcomes of care. This paper attempts to ascertain the underlying basis for an observed differential in physicians' tendency to advice activity restrictions for male and female patients. …
Results reveal that the odds of prescribed activity restrictions are 3.6 times higher for female patients than for males with equivalent characteristics. The observed differential is not explained by differences in male and female patients' health or role responsibilities. Gender differences in illness behavior and physician gender biases both appear to contribute to the observed differential. Female patients exhibit more illness behavior than males, and these behaviors increase physicians' tendency to prescribe activity restrictions. After accounting for illness behavior differences and all other factors, the odds of prescribed activity restrictions among female patients of male physicians is four times that of equivalent male patients of those physicians. Medical practice, education, and research must strive to identify and remove the likely unconscious role of social bias in medical decision making.
I suspect that further investigations would reveal even more circumstances of gender bias by physicians. Obviously this is not a healthy part of health care. What can we do about this? What should I be doing different in my teaching of first and second year medical students as they are introduced into clinical medicine? Will the fact that more and more women are becoming physicians (our current med school student classes are half men and half women) make a constructive difference?
Any answers? ..Maurice.
I would ask what the motivations for the differences are, first and foremost. Are they due to women's perceived lack of intelligence, or women's perceived fragility? Are they based on a mutual respect between men that one should not interfere in another's life? Are they based on a perception that even if they are prescribed lifestyle restrictions, men are unlikely to adhere to them? Before a way forward can be found, the question of why this behaviour occurs needs to be answered, because the resolution is dependent on that.
This is really interesting, I am a small business owner with 150 employees. I provide health insurance, one of the requirements mandated by the government is called the Janice law, it requires me to notify the employees every year that breast cancer screening, prework, mammograms, etc are all covered under our insurance plan. They do not have that same requirement for prostrate cancer screening through the rate of occurance is higher than breast cancer. Breast cancer is a topic in the media more frequently than any other health topic. Is what you referring to something you see as more of a provider issue than society at large? African Americans are far more likely to die from cancer than whites, do you think they are facing the same issues in the medical system?
As I understand it, the law that Anonymous from today notes is the Women’s Health and Cancer Rights Act—known as Janet’s Law. I put this issue up on a bioethics listserv that I subscribe and so far none of the ethicsts/legal wizards there have identified a similar law, requiring employer notification about insurance covering prostate cancer screening for their male employees. However, in California, where I live, a law does require a PSA test to be part of all insurance plans. Further, showing some equality in the responsibilities of physicians to adequately inform treatment options to men as well as women with prostate and breast cancer respectively, in California there are two laws which give some equality to physician responsibilites regarding prostate cancer evealuations:
Cal Bus & Prof Code § 2248
Failure to provide information on diagnostic procedures relating to prostate gland
This section shall be known as, and may be cited as, the Grant H. Kenyon Prostate Cancer Detection Act.
(a) If a physician and surgeon, during a physical examination, examines a patient's prostate gland, the physician and surgeon shall provide information to the patient about the availability of appropriate diagnostic procedures, including, but not limited to, the prostate antigen (PSA) test, if any of the following conditions are present:
(1) The patient is over 50 years of age.
(2) The patient manifests clinical symptomatology.
(3) The patient is at an increased risk of prostate cancer.
(4) The provision of the information to the patient is medically necessary, in the opinion of the physician and surgeon.
(b) Violation of subdivision (a) constitutes unprofessional conduct and is not subject to Section 2314.
and in addition
Health and Safety Code 109282, requires posting notice of that pamphlet widely:
(a) Every person or entity who owns or operates a health facility or a clinic, or who is licensed as a physician and surgeon and rents or owns the premises where his or her practice is located, shall cause a sign or notice to be posted where prostate cancer screening or treatment is performed by any physician and surgeon, or in a reasonably proximate area to where prostate cancer screening or treatment is performed. A sign or notice posted at the patient registration area of the health facility, clinic, or physician and surgeon's office shall constitute compliance with this section.
(b) The sign or notice shall read as follows:
"BE INFORMED"
"If you are a patient being treated for any form of prostate cancer, or prior to performance of a biopsy for prostate cancer, your physician and surgeon is urged to provide you a written summary of alternative efficacious methods of treatment, pursuant to Section 109280 of the California Health and Safety Code."
As I noted above a similar law in California applies to the full disclosure by the physician to a woman who was diagnosed with breast cancer of all the possible therapeutic options available to her verbally and/or with a hand-out pamphlet.
What I see has happened in California regarding breast and prostate cancer is that despite the fact that while the value of screening for breast cancer is virtually unchallenged, there remains much controversy regarding the long term benefit and improved quality of life of PSA prostate cancer screening in men and yet California is giving both genders equal attention to screening tests and education about screening and therapeutic options. ..Maurice.
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