Despite good intentions, gender bias persists in health care. A survey conducted in early 2019 by TODAY found that more than one-half of women, compared with one-third of men, believe gender discrimination in patient care is a serious problem. One in five women say they have felt that a health care provider has ignored or dismissed their symptoms, and 17% say they feel they have been treated differently because of their gender— compared with 14% and 6% of men, respectively.
Studies show that women’s perceptions of gender bias are correct. Compared with male patients, women who present with the same condition may not receive the same evidence-based care. In several key areas, such as cardiac care and pain management, women may get different treatment, leading to poorer outcomes.
Few physicians think intentional discrimination is at play here. Instead, it’s a result of the vestiges of disproved beliefs and outdated conventions. “The origins of this situation go back many years,” explains Janine Clayton, MD, director of the Office of Research on Women’s Health (ORWH) at the NIH. Much of medical science is based on the belief that male and female physiology differ only in terms of sex and reproductive organs, she says. Because of this, most research has been conducted on male animals and male cells, Clayton explains. “This is a major root of this issue.”
In addition, women—especially those in child-bearing years—were excluded from clinical trials for many years, in part to protect them and their fetuses from potential adverse effects. Researchers also felt that they could not adequately control for women’s variable hormonal status.
“Because we have studied women less, we know less about them,” Clayton says. “The result is that women may not have always received the most optimal care.”
Increasing the Knowledge Base
Women now constitute approximately one-half of participants in NIH-supported clinical research, which has increased the knowledge base about sex and gender differences.
“We now know that sex affects cell physiology, metabolism, and many other biological functions; symptoms and manifestations of disease; and responses to treatment,” says Clayton, pointing out that this research has led to a better understanding of both male and female physiology—knowledge that is critical as we move further into an era of precision/personalized medicine. The ORWH website (www.nih.gov/ women) provides free courses on sex and gender differences in medicine that are open to the public. It also contains an A-to-Z guide on sex and gender influences on health and disease.
“It is important for everyone who works in a medical practice to know how sex and gender—as well as age and race/ethnicity—affect health,” says Clayton.
Recognizing and Addressing the Problem
Office-based physicians may face challenges when trying to recognize and address the effects of unintended gender bias in their practices, says Calvin Chou, MD, a primary care physician at the San Francisco Veterans Affairs Medical Center and a senior faculty adviser for external education for the Academy of Communication in Healthcare. “We interact with our patients one by one, without much [outside] observation.” Additionally, time constraints in a medical practice can encourage some clinicians to inadvertently cut corners or jump to conclusions during patient visits.
“I don’t think there are any practitioners who imagine that they are delivering different care based on gender,” says Chou. “The first step is awareness. You can’t change your practices without awareness.”
“Biases are not moral failings; they are habits of mind,” adds Denise Davis, MD, clinical professor of medicine at the University of California, San Francisco, and faculty physician at the San Francisco Veterans Affairs Medical Center. With effort, habits can be changed. The following tips can help clinicians identify and combat gender bias.
- Diverse health care teams. Explicitly encouraging discussion of gender or other bias during team huddles can help team members feel comfortable speaking up about any concerns.
- Open-ended questions. Questions that elicit a limited range of responses from patients are more easily “contaminated by bias,” Davis says. However, open-ended questions pave the way to optimal patient care. For example, clinicians can ask, “What are your concerns today? What am I missing that is important for us to talk about?”
- Substitution. If Davis thinks bias may be slipping into her patient interaction, she asks herself what questions she would ask if the patient was a different gender. For example, she might be more likely to ask a young male patient about substance use or risky behavior, such as having guns at home. Additionally, she might assume a female patient has an ample social support system. Any of these assumptions can lead to missed opportunities for more comprehensive patient care.
- Data collection and analysis. Collecting and analyzing data can illuminate differences in care that would otherwise go undetected. Davis suggests first examining areas where disparities have been documented, such as in rates of cardiology consultations.
- Checklists and guidelines. Using computerized checklists that prompt providers to ask patients about risk factors, for example, can help ensure all patients undergo the same evaluation. Similarly, clinical guidelines for patient care can ensure that clinicians follow evidence-based methods for all patients.
- Training opportunities. Bringing in practice coaches or attending training opportunities on patient experience or patient communication can also help clinicians become aware of their own biases.
“Awareness of the problem is growing, as is an appreciation of the fact that women can have different diagnostic and treatment needs. I am hopeful that gender bias in health care will decrease over time,” Clayton says.