SGEM Xtra: From EBM to FBM – Gender Equity in the House of Medicine

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Date: October 7th, 2021

This is an SGEM Xtra episode. I had the honour of co-presenting at the Renaissance School of Medicine, Stony Brook University, Department of Emergency Medicine Grand Rounds. The title of the talk “From EBM to FBM – Gender Equity in the House of Medicine.

You may be wondering: why is a middle aged, white, heterosexual, cis gender, male, atheist, nerd co-presenting on gender equity in the house of medicine? “And isn’t it ironic, don’t you think? A little too ironic. And, yeah, I really do think”.

According to Sir Patrick Steward (Captain Jean-Luc Picard from Star Trek), “People won’t listen to you or take you seriously unless you’re an old white man, and since I’m an old white man I’m going to use that to help the people who need it”

My co-presenter was Dr. Suchismita Datta. She is an Assistant Professor in the Department of Emergency Medicine and GME Diversity Leader for the NYU Long Island School of Medicine.

The presentation is available to listen to on iTunes and GooglePlay and all the slides can be downloaded using this LINK.

Three Objectives

Recognize gender inequity in medicine
Identify gender inequities in each of the three pillars of of evidence-based medicine (EBM)
Understand how gender inequities can impact the cardiovascular care of women

Dr. Datta’s Journey

Dr. Datta

Dr. Datta shares her personal journey from medical school to attending physician and discusses the challenges she faced along the way.

She and her husband Neil met at medical school. They both matched to the same emergency medicine (EM) program. After graduation they began working at a high-volume, high-acuity critical access hospital. After a few years they moved back to New York.

Dr. Datta describes her unpaid and paid maternity leave, difficulties in pumping breast milk while on shift and the pay gap she experienced.

Gender Inequities Using the EBM Model

There are three pillars of EBM. The literature should inform care, guide care but it should not dictate care. Clinicians must also use their good clinical judgment in applying the literature. We also need to ask patients about what they value and prefer. This can be summarized into a Venn diagram capturing the Dr. Sackett’s definition of EBM.

The Medical Literature:

Who gets most of the grant money in medicine? Men
Who rises to the top academic positions at universities? Men
Who rises to the top academic positions in medicine? Men
Who rises to the top academic positions in Emergency Medicine? Men
Who is most likely to be the first author on a medical publication? Men
Who is most likely the first author on a emergency medicine publication? Men
Who is most likely to be the first author on a Pediatric Emergency Medicine (PEM) Paper? Men
Who are often excluded from being subjects in medical research? Women

The Clinicians:

Who historically has been the clinician in the room? Men
Who is most likely to rises to top leadership positions within the hospital structure? Men
Who gets paid more in medicine? Men
Who gets paid more in academic medicine? Men
Who gets paid more in academic Emergency medicine? Men
Who is more likely to be introduced with their professional title at grand rounds? Men
Who get’s paid more in Ontario, Canada? Men
What can be done about the gender pay gap? CMAJ 2020

The Patients:

Who traditionally was more likely to access health care? Women
Who is typically responsible for most family health care needs? Women
Who has been systemically under-treated when it comes to painful conditions? Women
Who are provided less care for life threatening illnesses like STEMIs? Women

Cardiovascular Disease in Women

Gender biases and inequities can seriously impact our clinical management. Cardiovascular disease in women is understudied, women are underrepresented in clinical trials, CVD is under recognized in women, they are being under diagnosed and under treated. This is associated with women having worse outcomes compared to men for this clinical situation.

Women presenting with without the classic chest pain during coronary syndrome were less likely to receive timely therapies. This included less fibrinolytics and less primary percutaneous intervention (Canto et al JAMA 2012 and Rogers et al Circulation 2012)
Women get the same benefit from PCI but have been shown to have more experience periprocedural complications (Alexander et al Circulation 2006, Regitz-Zagrosek et al Our Heart J 2011 and Dey et al Heart 2009)
Women with atypical presentations were also less likely to receive aspirin, other antiplatelet agents, heparin, and beta-blocker therapies during their hospitalization (Canto et al JAMA 2012 and Rogers et al Circulation 2012)
Women had a 4% absolute higher in-hospital mortality after presentation with ACS when compared to men (Canto et al JAMA 2012)
Women and cardiovascular disease Commission: reducing the global burden by 2030 (Vogel et al Lancet 2021)

Conclusion

We hope that Dr. Datta’s personal journey helps you recognize that gender inequity does exist in the house of medicine.

You can appreciate that there are systemic gender inequities in each of the three pillars of EBM and we should be working towards a Humanist-Based Medicine (HBM) model that is inclusive of everyone.

Understand how these gender inequities can have serious impact our clinical management. The example we used was that women with cardiovascular disease were under-diagnosed, under-treated and had worse outcomes compared to men.

The SGEM will be back next episode doing a structured critical appraisal of a recent publication. Trying to cut the knowledge translation window down from over ten years to less than one year using the power of social media. The ultimate goal of the SGEM is for patients get the best care, based on the best evidence.

REMEMBER TO BE SKEPTICAL OF ANYTHING YOU LEARN, EVEN IF YOU HEARD IT ON THE SKEPTICS’ GUIDE TO EMERGENCY MEDICINE.

Additional Reading:

Davies RE, Rier JD. Gender Disparities in CAD: Women and Ischemic Heart Disease. Curr Atheroscler Rep. 2018 Sep 4;20(10):51. doi: 10.1007/s11883-018-0753-7. PMID: 30178384
Mehilli J, Presbitero P. Coronary artery disease and acute coronary syndrome in women. Heart 2020;106:487-492.
Greenwood BN, Carnahan S, Huang L. Patient-physician gender concordance and increased mortality among female heart attack patients. Proc Natl Acad Sci U S A. 2018 Aug 21;115(34):8569-8574. doi: 10.1073/pnas.1800097115. Epub 2018 Aug 6. PMID: 30082406; PMCID: PMC6112736
Nguyen PK, Nag D, Wu JC. Sex differences in the diagnostic evaluation of coronary artery disease. J Nucl Cardiol. 2011;18(1):144-152. doi:10.1007/s12350-010-9315-2
Lichtman JH, Leifheit EC, Safdar B, Bao H, Krumholz HM, Lorenze NP, Daneshvar M, Spertus JA, D’Onofrio G. Sex Differences in the Presentation and Perception of Symptoms Among Young Patients With Myocardial Infarction: Evidence from the VIRGO Study (Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients). Circulation. 2018 Feb 20;137(8):781-790. doi: 10.1161/CIRCULATIONAHA.117.031650. PMID: 29459463; PMCID: PMC5822747
Mosca L, Benjamin EJ, Berra K, Bezanson JL, Dolor RJ, Lloyd- Jones DM, et al. Effectiveness-based guidelines for the prevention of cardiovascular disease in women–2011 update: a guideline from the American Heart Association. Circulation. 2011;123:1243–62
Bank IEM, de Hoog VC, de Kleijn DPV, et al. Sex-Based Differences in the Performance of the HEART Score in Patients Presenting to the Emergency Department With Acute Chest Pain. J Am Heart Assoc. 2017;6(6):e005373. Published 2017 Jun 21. doi:10.1161/JAHA.116.005373