It’s All in Your Head: Implicit Bias Results in “Bad Medicine” for Women

by Leslie Kumler

“I had abdominal surgery and the doctor took me off my pain meds two days later. That night, I experienced the most excruciating pain in my abdomen. It was very intense. The next morning, still in pain, I told my doctor. He said I was being sensitive and sent me home. I ended up back in the hospital 24 hours later with a deadly infection called peritonitis and was suffering sepsis. My doctor almost killed me by brushing off my pain,” said Michelle R., sharing her personal experience.[1]

Society has been taking women seeking medical treatment less seriously than men for centuries. In the 1800s, women who complained of physical maladies were called “hysterical” and sent to mental asylums. Some were forced to have hysterectomies. Hysteria, an ill-defined diagnosis exclusively applied to women, was still part of the Diagnostic and Statistical Manual of Mental Disorders until 1980.[2] Very recently, studies have shown that women are dying at alarming rates from preventable or treatable causes during or soon after childbirth. Unconscious or implicit bias in medicine is at the heart of the problem. Everyone in every profession has some level of unconscious bias, but in medicine, it can cause patients to suffer needlessly for years and, in some cases, result in death. Researchers suggest important steps that can be taken by healthcare providers to decrease their unconscious bias and improve medical treatment of women.

What is Implicit Bias and How Does it Manifest?*

Implicit bias, also known as unconscious bias, happens when subtle, unconscious processes in cognition cause a bias in judgment or behavior. It happens in every area of life and across all professions, but in medicine, implicit bias can result in negative outcomes ranging from its most severe, death, to challenges with treatment compliance and failure to return for additional treatment. Studies show that implicit bias may be based on a patient’s sex, race, primary spoken language, sexual orientation, and perceived education and profession.[3] A healthcare professional may manifest implicit bias while communicating with the patient, recommending treatment choices, giving options for pain management, diagnosing, and more.[3]

Alarming Statistics

As more research on gender disparity in medical treatment has been done in the last two decades, staggering statistics indicate that long-held, often erroneous beliefs about the differences in pain tolerance and symptom reporting from women have led to undertreatment of pain and delayed diagnoses. In a study published in Academic Emergency Medicine, researchers found that when women and men had similar pain scores, women were 7-9% less likely to receive analgesics for abdominal pain in the ED, even when gender-specific diagnoses were excluded. They were also 13-25% less likely to receive opioid analgesics, even after controlling for age, race, triage class, and pain score. Women waited an average of 16 minutes longer to receive any type of analgesia for their abdominal pain than men.[4] A study published in the Official Journal of the Society to Improve Diagnosis in Medicine (SIDM) found that males had “25% lower odds of misdiagnosis” of stroke than females in the emergency room setting.[5] “More than 40 percent of women eventually diagnosed with a serious autoimmune disease have basically been told by a doctor that they’re just too concerned with their health or they’re a hypochondriac,” says Virginia Ladd, founder and executive director of the American Autoimmune Related Diseases Association.[6] Before being diagnosed with an autoimmune disease, patients see an average of 4 doctors over 3 years, according to research conducted by the association.

It’s All in Your Head: Women’s Pain Experience

Autoimmune diseases like multiple sclerosis, rheumatoid arthritis, and chronic fatigue syndrome, many of which cause chronic pain, are 3 times more likely to occur in women than in men. 65% of women with chronic pain taking a survey conducted by the National Pain Report said they feel doctors take their pain less seriously because they are female. 84% feel doctors treated them differently because they are women. 49% prefer female doctors because they understand their female patients’ pain better.[7] 75% of women reported that a doctor had told them “You’ll have to learn to live with your pain,” and 45% had been told “The pain is all in your head.”[8] Women with endometriosis, in particular, can spend a long time in pain before they have a diagnosis. They are told that having pain with a period is normal, that they are exaggerating their pain, that the pain is a result of anxiety, or worse, that they are imagining it.[9]

Dying as a Result of Childbirth: A Modern Day Epidemic

In a widely publicized story, tennis champion Serena Williams found herself in a life-threatening situation after giving birth to her daughter by emergency Cesarean section. She had a history of blood clots and had stopped using blood thinners before the delivery. When she started experiencing shortness of breath after the delivery, she told her health care providers that she was likely having a pulmonary embolism. The medical staff instead assumed she was confused as a result of taking painkillers and ignored her requests for a CT scan and blood thinners. A CT scan later confirmed Williams’ suspicions.[10]

The U.S. now has the highest rate of maternal death in the developed world by far at 26.4 deaths per 100,000 live births. The next closest is the U.K. with a rate of 9.2.[11] 700-900 women die every year from pregnancy or childbirth-related causes and 65,000 women experience a near-fatal emergency during pregnancy, childbirth, or soon after giving birth.[11] Some of these pregnancy and childbirth-related deaths have a variety of causes in addition to implicit bias, however 98% are considered preventable.⁸ Researchers have found that “’delay and denial’ – the failure of doctors and nurses to recognize a woman’s distress signals or other worrisome symptoms”[12] is a contributing factor in many cases. “By and large, pregnant women are going to do OK, almost no matter what you do, until they don’t,” said Elliott Main, medical director of the California Maternal Quality Care Collaborative. “The large majority will do fine. That makes people assume, even in the light of symptoms, that with some time, the bleeding will stop, it’s going to be OK, I just have to wait it out a little longer.”[12]

Making Medical Decisions Without Bias

In 2006, Dr. Elliot Haut and his team at Johns Hopkins Hospital in Baltimore were alarmed to discover a systemic gender bias in the diagnosis of preventable blood clots. They found that although both men and women were not receiving treatment at ideal rates, 45% of female trauma patients did not receive clot prevention compared to 31% of men. Haut’s team developed a clot prevention protocol – a checklist – that would be mandatory for health care providers to review with every patient. Once the checklist was in use, the gender disparity was gone and appropriate clot prevention for all patients spiked.[13] Checklists like the one developed at Hopkins are considered decision support tools. When well-implemented and with buy-in from doctors, nurses, and other healthcare practitioners, such decision support tools can help to mitigate and even eliminate implicit bias. The Institute for Healthcare Improvement and Dr. Augustus White, author of Seeing Patients: Unconscious Bias in Health Care, make several helpful suggestions to help mitigate unconscious bias:

• Recognize that you have responses based on stereotypes and make a conscious effort to adjust your response
• Imagine the patient as the opposite of the stereotype
• See each patient as an individual by listening carefully to the patient’s history and context for their visit
• Put yourself in the patient’s shoes
• Take care to practice evidence-based medicine – employ checklists and use decision support tools to support this practice
• Make a concerted effort to expand your own network to include different racial and ethnic groups, gender identities, and so on
• Consider your interactions with a patient to be a collaboration of equals
• Recognize when a situation might magnify your bias
• Use the teach-back method to ensure your patient fully understands their diagnosis and instructions for treatment
• Make an effort to understand the basics of the cultures your patients come from

Your Patients Will Thank You

As Dr. Janice Werbinski, the executive director of the Sex and Gender Women’s Health Collaborative says, “Doctors are trying to do the right thing. It’s not that they’re trying to be mean or dismissive.”[2] Making a concerted effort to treat patients without bias can make an enormous difference in their experience of health care. In many cases, it doesn’t just provide a better quality of life, it saves lives.

*Author’s note: Implicit bias comes into play not only in treating women, but also across race, sexual orientation, culture, and socioeconomic lines. This is an enormous topic and challenging to address in one article. We hope to address other disparities in treatment of patients in future articles. For the moment, we want to acknowledge the existence of the problem across the spectrum and the intersectionality involved.

References

1. Parker L. 29 Women Share Their Stories Of Doctors Not Taking Their Pain Seriously. BuzzFeed. https://www.buzzfeed.com/laraparker/women-pain?utm_term=.wfXpXLPG8#.jl1EBJ8e1. Published March 20, 2017. Accessed June 14, 2018.

2. Culp-Ressler T. When Gender Stereotypes Become A Serious Hazard To Women’s Health. ThinkProgress. https://thinkprogress.org/when-gender-stereotypes-become-a-serious-hazard-to-womens-health-f1f130a5e79/. Published May 11, 2015. Accessed June 14, 2018.

3. How to Reduce Implicit Bias. Institute for Healthcare Improvement. http://www.ihi.org/communities/blogs/how-to-reduce-implicit-bias. Published September 28, 2017. Accessed June 14, 2018.

4. Chen EH, Shofer FS, Dean AJ, et al. Gender Disparity in Analgesic Treatment of Emergency Department Patients with Acute Abdominal Pain. Academic Emergency Medicine. https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1553-2712.2008.00100.x. Published March 29, 2008. Accessed June 14, 2018.

5. Newman-Toker DE, Moy E, Valente E, Coffey R, Hines AL. Missed diagnosis of stroke in the emergency department: a cross-sectional analysis of a large population-based sample. Official Journal of the Society to Improve Diagnosis in Medicine (SIDM). https://www.degruyter.com/view/j/dx.2014.1.issue-2/dx-2013-0038/dx-2013-0038.xml. Published March 14, 2018. Accessed June 14, 2018.

6. Brown H. Women’s health problems doctors still miss. CNN. http://www.cnn.com/2009/HEALTH/10/19/undiagnosed.women.problem/index.html?eref=rss_latest. Published October 26, 2009. Accessed June 14, 2018.

7. Women in Pain Report Significant Gender Bias. National Pain Report. http://nationalpainreport.com/women-in-pain-report-significant-gender-bias-8824696.html. Published November 8, 2015. Accessed June 14, 2018.

8. Women in pain survey. https://www.surveymonkey.com/results/SM-P5J5P29L/. Accessed June 14, 2018.

9. Edwards L. Opinion | Women and the Treatment of Pain. The New York Times. https://www.nytimes.com/2013/03/17/opinion/sunday/women-and-the-treatment-of-pain.html. Published March 16, 2013. Accessed June 14, 2018.

10. Chéileachair CN. Why are so many American women dying in childbirth? Harvard Law: Bill of Health. http://blog.petrieflom.law.harvard.edu/2018/01/24/why-are-so-many-american-women-dying-in-childbirth/. Published January 24, 2018. Accessed June 14, 2018.

11. Martin N, Montagne R. Focus On Infants During Childbirth Leaves U.S. Moms In Danger. NPR. https://www.npr.org/2017/05/12/527806002/focus-on-infants-during-childbirth-leaves-u-s-moms-in-danger. Published May 12, 2017. Accessed June 14, 2018.

12. Ellison K, Martin N. Nearly Dying In Childbirth: Why Preventable Complications Are Growing In U.S. NPR. https://www.npr.org/2017/12/22/572298802/nearly-dying-in-childbirth-why-preventable-complications-are-growing-in-u-s. Published December 22, 2017. Accessed June 14, 2018.

13. Nordell J. A Fix for Gender Bias in Health Care? Check. The New York Times. https://www.nytimes.com/2017/01/11/opinion/a-fix-for-gender-bias-in-health-care-check.html. Published January 11, 2017. Accessed June 14, 2018.