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It
might come as a surprise to some, but the model of American medical
education in the twentieth century is based on the military model. The
hierarchical command structure is militaristic in nature, with the
physician on top of the command chain. The development of the culture of
Medicine in the U.S. has been profoundly influenced because of this model.
Since
the American military has traditionally been male-oriented and
male-dominated, it follows that medical training built on this foundation
tends to show a bias that downplays the importance of women — both as
physicians and as patients.
The
educational process begins at variable points for the specific individual.
There are those students who have always known that they wanted to
"be a doctor". For them, medical education began in elementary
school. Typically, the process begins in earnest during the High School
years, when thoughts of "what do I want to do with my life?"
begin. There are others, like me, who made this decision during their
college years, when the specter of finding a job versus furthering an
education came to the forefront.
Regardless
of the timing of the decision, the final common pathway is medical school.
In the United States, there are about 127 medical schools. Arrival at the
medical school of your choice is the result of extraordinary long hours of
study and perseverance and competition.
Like
a military bootcamp, the process of indoctrination takes place from the
very first day at medical school. A lot of time is spent talking about how
outstanding we all are, and how we are the "elite" who made it
in. After all of the self-congratulatory behavior, the realities set in.
We will take 8 to 12 classes each semester for the first year, and we must
pass them all.
With
what seems to be an impossible task before us, the focus is not so much on
learning and understanding, but upon the rote memorization of
"facts." I coined the term "factmaster" for myself
during the training process. Memorizing large amounts of unrelated
information was essential in order to pass the examinations later, and
questioning the nature of the information would have used up valuable
mental resources which then would not be available for memorization.
So
it is in this environment that biases in the content of medical knowledge
and education go overlooked and thus become accepted as another
"fact."
In
med school, "human physiology" was about male physiology. The
workings of the organ systems in the body: brain, heart, kidneys, lungs,
blood, marrow, and all the equations involved in explaining their actions
and interactions. Only after the basic male components of physiology were
completely explained and understood did we delve into what was considered
the "variant" of the "normal", i.e., female
physiology.
Similar
subtle biases were experienced in other classes: psychology and
psychiatry, pharmacology, neurosciences. This idea of female physiology as
a deviation from the "norm" carried over into the clinical
years, when variances from the basic male physiology were considered to be
complications and often regarded as treks into the unknown.
This
situation became obvious when, during the third year of medical school, a
rotation into obstetrics and gynecology was required. The gynecologist
knew about all these "deviations" from normal physiology. Women
of childbearing years were considered automatically problematic. They were
assumed to be pregnant unless proven otherwise. Because of this
assumption, many treatment protocols are withheld from them, or not even
considered.
Pregnancy
itself represented, in the context of this philosophy, a huge departure
from normal human physiology. All the rules regarding functioning of the
heart, bone marrow, immune system and nervous system changed. Ignorance
and the fear of doing the wrong things for a pregnant woman were common.
Doctors, faced with a departure from the familiar, often gave less
attention to these "deviant" physical specimens.
The
reasons for this state of affairs are complex, but there are a couple of
identifiable elements which may help to explain the situation.
Medical
research has focused on male subjects because historically it was
considered "indelicate" to experiment on women. Since many of
the experiments done on living humans involved some degree of risk, it had
always been felt that women should not be involved in such risk. This is
not unlike the attitude of many towards women in the military.
Another
major consideration is that women of childbearing years are assumed to be
pregnant. The risks of complicating a pregnancy because of medical
experimentation were considered unacceptable. Prior to the 1960s this was
an ethical decision, and afterward, a liability-based decision as well.
The
result is that physicians come out of med school harboring an attitude
towards female patients that is hardly conducive to providing the best
health care to women. Even female physicians are not immune to this
insidious indoctrination.
Women
often complain that their doctors treat them as "inferiors"
and/or seem to brush off their concerns about their conditions. How could
it be any other way, when physicians’ training has emphasized repeatedly
that there is something inherently "wrong" with the female body,
that regardless of how healthy it is, it’s still somehow
"abnormal?"
Before
we can expect doctors to change their ways of interacting with the women
whose illnesses they treat, we have to change the way they’re educated,
so that they don’t equate the very state of being female with
abnormality.
Thomas
W. Shinder, MD,
is a neurologist-turned-network systems engineer
who practiced medicine in Texas, Oregon and Arkansas before moving to his
present home in the Dallas-Ft. Worth TX metropolitan area.
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