Redressing the balance

Following research that found that men were more likely to receive life-saving CPR than women, Tatum Anderson delves deeper, asking how much gender bias there is in healthcare.

Cardiopulmonary resuscitation (CPR) saves lives and tens of millions of people have been trained to perform it. But a recent piece of research found that men were more likely to receive life-saving CPR than women. And, scarily, were more likely to survive.
Researchers looked at who aids people having a heart attack or stroke in public settings. They found that while 45 per cent of men received assistance, only 39 per cent of women did. And, as a result, men had a 23-per-cent increased chance of survival compared to women.
Many different hypotheses have been suggested to account for the difference in who is given CPR – perhaps some people are reluctant to perform CPR on women for fear of touching breasts, for example. But Audrey Blewer, Assistant Director for Educational Programmes at the Center for Resuscitation Science, University of Pennsylvania, US, who carried out the research, said the reasons are still unclear. “It’s an interesting finding and it probably opens off a lot of questions and areas for enquiry going forward,” she said. “We haven’t really done too much of in terms of research in the resuscitation community.”
In fact, says Blewer, her decision to look at CPR is based on growing information on how women are treated in the rest of the healthcare system. “I think that there is a lot of precedent and current publications looking at gender bias in terms of clinicians, prescriptions and various types of medication or even procedures in the cardiovascular field,” she said. “We are also seeing differences in emergency response. A lot of that motivated our thinking about whether there may be differences in terms of gender bias in individuals doing CPR in a cardiac arrest victim.”
There have long been shocking employment and pay disparities between male and female doctors and nurses. But the research highlights an increased interest in understanding how a woman and a man may be treated differently at a hospital, in an emergency room or any part of the healthcare system. In other words, how much gender bias is there in healthcare?

Across the spectrum
The Institute of Medicine’s landmark publication Unequal Treatment describes gender bias as unequal access or treatment that is not justified on the basis of an underlying health condition. In a healthcare setting, bias against women may be manifested when women are diagnosed, counselled, treated, or otherwise managed not just differently, but to a lesser degree of adherence to established standards of care than men with comparable health status, it said. Scarily, the bias has potentially lethal effects such as higher complication, morbidity, and mortality rates.
Gender bias is not the same as gender disparity, where there are fundamental anatomic and physiologic attributes that result in differences to exposures and risks, and it is necessary to effect appropriate treatment adaptations and outcomes for each gender.
Worryingly, for over 20 years, researchers have found widespread differences between the way men and women are treated. One study found that critically-ill women aged 50 years and older were less likely than critically ill men to be admitted to an intensive care unit (ICU) and to receive potentially life-saving interventions, and they were more likely to die in ICU or in hospital.
More studies suggest women with strokes were less likely to receive appropriate diagnostic imaging, antithrombotic therapy, or carotid revascularisation as inpatients. They must wait longer after they arrive in the emergency department and receive less aggressive treatment and therapeutic workup following their admission too. They are less likely to receive implantable cardiac defibrillators after an out-of-hospital cardiac arrest or implantable cardiac defibrillators when indicated for congestive heart failure, or to be admitted to an acute care hospital and receive coronary revascularisation procedures when presenting with coronary syndromes than men.
Female trauma victims with life-threatening injuries were less often triaged by emergency medical service personnel to trauma facilities and less often transferred by non-trauma physicians to trauma centres.
In fact, gender bias appears to exist across a wide spectrum of clinical practice areas, ranging from management of cardiovascular risk factors, surgery, and orthopaedics to behavioural health, acute and critical care. And it is worldwide.

Unconscious prejudices?
Bias happens not only within emergency care, but to primary care appointments, referrals for investigations, diagnosis times, and starting procedures such as dialysis, say researchers. One study looked at German GPs who examined both men and women for chest pain. They were more likely to refer men to the hospital for exercise tests, assuming more frequently that men had coronary heart disease.
One medical journal editor expressed shock at the growing body of research in a review last year. When patients enter any healthcare system, especially with life-threatening health conditions, it’s implicitly assumed that the care they receive is dictated by sound clinical judgement and objective evidence-based parameters derived from reliable research, said JoAnn Grif Alspach, Editor of the journal Critical Care Nursing. “Nowhere in that scenario do we anticipate that clinical decision making will be influenced by patient attributes such as religion, nationality, socioeconomic class or any other feature not relevant to their specific clinical situation,” she said.
Dr Elliott R. Haut, a trauma surgeon and expert in quality and Associate Professor of Surgery at The Johns Hopkins University School of Medicine, has looked at bias within his own department. He believes bias is generally an unconscious decision. “I wouldn’t expect there to be a bias, because as a physician you don’t think you are biased. You don’t think you are doing anything differently. But there are many things you may not know you are doing.”
Some think gender bias is an expression of prejudice that is believed to be implicit, operating at an unconscious level on the basis of situational cues.
Look at one study on total joint arthroplasty (TJA). It’s a procedure that is underused by more than three times as many women as men with qualifying knee osteoarthritis. So researchers sent one man and one woman with moderate knee osteoarthritis and otherwise identical clinical backgrounds to visit 71 physicians (38 family care and 33 orthopaedic surgeons). Results showed that 42 per cent of physicians recommended TJA to the male but not the female patient, whereas eight per cent of physicians recommended TJA for the female but not the male patient.
Most interestingly, the physicians’ professed attitudes related to the role of gender in these decisions were contradicted by their actual practise.
Underestimating or misunderstanding a woman’s risk for health problems or complications may be down to the differences in how diseases affect men and women. “I don’t think people do it consciously. It’s more that a disease may affect men more than women or women more than men. These kinds of thoughts are not bias, they are the truth. It’s hard to differentiate sometimes,” said Dr Haut.
Researchers suggest that women tend to describe what they experience as a more personal, narrative commentary compared to men, who typically describe symptoms in a more straightforward, factual manner with fewer comments. In fact, women’s narrative presentation style has led to physicians making more diagnostic errors in their evaluations of chest pain in women.

Some think gender bias is an expression of prejudice that is believed to be implicit, operating at an unconscious level on the basis of situational cues

Of course, some of it may be down to unconscious prejudices among physicians and some might even be overt discrimination based on sex. Some physicians take women’s symptoms less seriously, attributing symptoms to emotional rather than physical causes.
That is true of chronic pain, which is thought to affect tens of millions of people around the world. Professor Joanna Zakrzewska, of the Eastman Dental Hospital, who specialises in the excruciating burning mouth syndrome and trigeminal neuralgia, says the conditions are not taken seriously and tend to affect women more than men. They are often dismissed by doctors. “It’s mainly middle-aged women and they get chucked out of the surgery,” she said.

Mitigating bias
Luckily, there has recently been some evidence that bias can be mitigated by the use of checklists. These are aids for doctors, when diagnosing or treating patients, and help them to remember the various checks and considerations they must keep in mind when approaching their patients.
They have been championed most notably by Dr Atul Gawande, a surgeon in general and endocrine surgery at Brigham and Women’s Hospital, US, in his 2009 book The Checklist Manifesto. Dr Gawande has written broadly on modern medicine and ways to improve it. He posits that the idea that no matter how expert an expert is, well-designed check lists can improve outcomes (even for Gawande’s own surgical team).

If you know you have a bias you may make a more conscious decision to try and overcome that bias. Nobody goes into medicine thinking I’m going to treat men better than women. That’s not why we are in medicine

But they’ve been shown to make a massive difference to bias too. In 2005, Haut’s group at Johns Hopkins discovered a discrepancy in the way trauma patients received appropriate venous thromboembolism (VTE) prophylaxis to prevent blood clots. They discovered 31 per cent of male trauma patients did not receive VTE prophylaxis, whereas in female trauma patients, that failure rate was 45 per cent, making women nearly 50 per cent more vulnerable to blood clots.
The hospital had already introduced checklists to improve the quality of services across all patients. But, when they identified how the data had affected outcomes, they realised that there had been a bias that was removed by using the checklist.
The checklist works something like this: when a doctor enters medical orders for such patients, the automated checklist recommends evidence-based best treatments for each patient’s needs, usually the regular administration of low-dose blood thinners or the use of compression devices to keep blood flowing in the legs.
The researchers say this new system worked far better than previous methods, which included handing out laminated cards outlining best practices or lectures presented on the topic of preventing venous thromboembolism (VTE), a term that covers dangerous clots in the legs and lungs. That’s because the electronic system prevented doctors from progressing in their work until they had considered everything on the checklist.
The results were startling. There was nearly a two-fold improvement in prophylaxis orders among patients who had no contraindications to receiving the low-dose blood thinners. The rate of deep vein thrombosis (DVT) in legs dropped nearly 90 per cent, from 2.26 per cent of trauma patients to 0.25 per cent of trauma patients in the final year of the study. Now, checklists are the standard of care throughout the hospital.

Highlighting discrepancies
Many hospitals around the world use checklists already. In fact, special checklists have been developed for use in surgery, and are also used in low- and middle-income countries to save lives around the world.
However, Haut says checklists are more likely to be used to improve quality – which has been a big trend in recent years – rather than to remove bias. Tackling gender bias, unfortunately, is in its infancy. “The world of quality is about 10 years ahead of the world of studying biases in healthcare,” he said. “There is now more interest in the bias piece.”
In the future, hospitals may be able to use electronic checklists to pinpoint just how well individual doctors are doing, in terms of gender bias. That would help identify those doctors who are more likely to miss certain symptoms, and treatments. However, determining that may not be as easy as it seems because so many doctors tend to work in medical teams.
Haut believes making people aware of the bias will make a difference. “If you know you have a bias you may make a more conscious decision to try and overcome that bias,” he said. “Nobody goes into medicine thinking I’m going to treat men better than women. That’s not why we are in medicine.”
Maybe tackling gender bias is down to education, too. The University of Pennsylvania’s Blewer said that it’s imperative to look at the way people are trained to do resuscitation in first-aid courses. She notes resuscitation dolls are always male, for example, and maybe they need to be female. Or perhaps there should be more training to highlight the discrepancy, so it is brought to the conscious mind. “We’ve found disparities in terms of race and socioeconomic status, now gender, in terms of CPR, maybe we need to think about ways to address some of these attentional biases in training courses, either through how we communicate or how we train people in a stimulating environment,” she said.