One size fits… male?

Patient and doctor

‘Man-flu’ memes and the celebration of women’s endurance hide the reality that the medical world routinely downplays women’s pain and disease. Miriam Calleja takes a closer look.

We often hear that women are more tolerant to pain than men. Many are also proud of it. However, in the famous game-changing paper titled ‘The Girl Who Cried Pain: A Bias Against Women In The Treatment Of Pain’ the authors Diane E. Hoffman and Anita J. Tarzian found that contrary to popular belief, women report more severe levels of pain, more frequent pain, and pain that lasts longer than men’s. Three Maltese women found out the hard way that confiding in medical practitioners does not always lead to help.

Culture and gender frame our behaviour around pain perception. Boys were, and some still are, told not to express pain by crying or showing emotion. Girls were told to calm down and not make a fuss. Pain meant weakness. Our language lacks the vocabulary to adequately describe pain. In ‘On Being Ill’, Virginia Woolf writes: ‘English which can express the thoughts of Hamlet and the tragedy of Lear, has no words for the shiver and the headache… The merest schoolgirl, when she falls in love, has Shakespeare and Keats to speak for her; but let the sufferer try to describe a pain in his head to a doctor and language at once runs dry.’

Gendering pain

By analysing a number of studies, Hoffman and Tarzian found that women are ‘more likely to be treated less aggressively in their initial encounters with the healthcare system until they prove that they are as sick as male patients.’ This is a phenomenon known as the Yentl Syndrome. In other words, doctors may brush female pain off as fabricated or exaggerated. This can impact diagnosis, disease progression, and treatment plans — delaying care and fueling mistrust.

Prescribing uterus removal when a woman was ‘rebellious’ may seem like ancient history, but that bias has not fully retreated. Until the early 1990s, women were mostly excluded from clinical research studies and trials in medicine. What we knew about the body, about disease, and about medicine was based on men. Drugs that didn’t work on men, but might have worked on women, were discarded. With incomplete data, the medical world may have lost opportunities to improve women’s health. Have today’s healthcare professionals been trained to counter this gender bias? 

Another doctor later referred Karen for an MRI, and the tumour was detected — a life or death analysis.

Antonia* doubts that. As a teenager she developed digestion problems and nausea every time she ate. When she complained, her family doctor downplayed the problem and suggested that she should just stop eating for a couple weeks. After this shocking response she ignored the issue for a long time, suffering in silence. Another doctor chalked it down to ‘growing pains’ and did not recommend a colonoscopy, even though Antonia asked for it.

Having received no satisfying response from her visits to medical professions, Antonia decided to do her own research, discovering that her symptoms matched the description of a condition called Crohn’s. Because of her constant discomfort and pain Antonia had no choice but to persist until she was granted testing and the correct treatment after years of suffering. This means that two doctors would have left her inflamed digestive system untreated, risking further damage.

Illustration by Gabriel Izzo

‘It is just a phase’

Women are often told that their ailments are due to stress or other emotional factors. A little rest would solve the problem; it is just a ‘phase’. Some doctors would call a woman insisting on referral for further testing a hypochondriac, even in the presence of positive clinical tests (see e.g. Samulowitz et al. 2018 study and numerous articles in the New York Times, The Atlantic and elsewhere). Thankfully, there are enough doctors who look beyond textbook-like symptoms. They make it a point to listen and investigate as much as necessary. Yet the burden of finding a practitioner ready to listen lies with the patient.

Karen visited her gynaecologist complaining of headaches and substantial weight gain. Test results revealed a high prolactin level, which is normally produced during pregnancy or right after giving birth. Yet when Karen asked to be referred for an MRI to investigate for tumours in the pituitary gland, the doctor refused, telling her that she was ‘making a fuss’. Another doctor later referred Karen for an MRI, and the tumour was detected — a life or death analysis. 

Some doctors would call a woman insisting on referral for further testing a hypochondriac, even in the presence of positive clinical tests.

Gynaecologists feature often when discussing gender bias. Without systematic training to counter biases, women are left to ‘shop around’ for a gynae that doesn’t shame them or belittle their wishes. This is surprising for a profession specialising in women’s health. 

Reproductive issues open another can of worms. Some women who decide not to have children are treated as though they don’t know what they’re doing. Their doctors imply that the patient will inevitably change their mind, or try to guilt the patient into considering the feelings of a hypothetical man they might meet.

You would think that commitment to bear biological children would be respected, but women who undergo IVF are often treated with insensitivity too. Sandra* and her husband had a harrowing story to tell me. Sandra’s gynaecologist decided to immediately hurry her to IVF after the first visit about their concerns at not being able to conceive. The gynaecologist was rarely present for her many appointments at hospital, leaving Sandra to be passed from one doctor to another, internally examined by various doctors without explanation or prior request for consent. With the exception of one doctor, none of them introduced themselves. All along she tried to ask questions, but was kept in the dark about the situation, going along with the doctors’ instructions but losing trust. The outcome of the first procedure was unsuccessful, and because of how traumatising all this felt, the couple decided not to try again.

Unlearning the bias

Pain is subjective and difficult to measure. An individual’s tolerance to pain is affected by various factors, and pain perception may change with time and experience. Pain causes distress, which makes it difficult to measure objectively. So how can overworked doctors make the best possible assessment?

In her thesis titled ‘The Chronic Pain Management Service: Awareness and Perceptions Among Healthcare Professionals’ (University of Malta, 2008), Maria Campbell studied pain perception in other healthcare professions in Malta back in 2008, finding out that outdated attitudes have not been challenged. She writes, ‘Incomplete knowledge, outdated attitudes, myths, and misconceptions about pain and its management contribute to unsafe, inadequate, and inappropriate pain management.’ Medical practitioners wanted to be more up-to-date: ‘The need for information in the form of leaflets, seminars, and continuing education was echoed in the overall answers (90%) of the close-ended question and in the statements declared by participants.’ But before this training becomes systemic, the radical act of listening to women is a good place to start. 

* Name has been changed

Further reading:

Fassler, J. ‘How Doctors Take Women’s Pain Less Seriously’. The Atlantic. October 2015.

Hoffman D.E., Tarzian, A.J. ‘The Girl Who Cried Pain: A Bias Against Women In The Treatment Of Pain’. Journal of Law, Medicine & Ethics, Vol. 29, pp. 13-27, 2001.

Campbell, M. ‘The Chronic Pain Management Service: Awareness and Perceptions Among Healthcare Professionals.’ University of Malta. June 2008. 

English for medicine: Bridging worlds

You come to Malta to attend Medical School, and you end up in an English class. Nicola Kirkpatrick talks to Dr Isabel Stabile, Omar N’Shea, and Edward Wilkinson about the often unappreciated value of the University of Malta’s Medical Foundation Programme and its impact on international medical students’ lives.

A sea of blank faces stared him down. Omar N’Shea had asked his students a question, but no reply came. None of them wanted to be there. The University of Malta’s Medical Foundation Programme (MFP) aims to equip high school graduates with less than 13 years of formal education with the skills they need to enter Medical or Dentistry school. But its focus on academic English is what receives the most ire. N’Shea, one of the programme coordinators, understands. ‘They don’t see the value initially. They think to themselves: ‘I didn’t travel thousands of miles away to sit in an English class. No, I want to study medicine.’ The frustration is understandable,’ he nods.

Omar N’Shea

But when so many international students were struggling with the medical course due to language and communication difficulties, something clearly had to be done.

Looking back at the challenges she was facing when the Medical School opened its doors to international students, Director of Studies Professor Isabel Stabile notes the discrepancy in language skills. What was expected was quite distinct from the reality of the situation. ‘What is interesting about our student body is that their spoken level of English is really high,’ says N’Shea, ‘but their written level of English needs work to keep up with the demands of an academic course.’

English Programme Coordinator and tutor Edward Wilkinson agrees, highlighting that ‘resources were lacking. Teaching exercises and materials were sourced online and everyone did the best they could. But a gap quickly emerged as far as Medical English was concerned.’ Stabile further clarifies, ‘Most books available were aimed at teaching doctors and nurses bedside manner and care for patients, but there was little to none out there that focused on academic medical English.’

Prof. Isabel Stabile

With this philosophy in mind, Stabile, N’Shea, and Wilkinson joined forces to develop a series of books called Academic Medical English for Pathway/Foundation Programmes. These books provided a framework for students to deal with the language in which scientific subjects are taught. The material improves their academic literacy in ways important to medical students, equipping them with skills such as reviewing research papers, writing reflective essays, and answering essay questions.

The book was ‘born out of the needs of these students and the medical program,’ says N’Shea. ‘The concept is to present to the students the core skills required by the medicine and surgery degrees, so that students become aware of the differences between using English as a lingua franca and using English within the framework of academic literacy.’ To enable this, the team included topics to reflect those covered in the science classes that students attend throughout the course. ‘So if they’re doing pulmonary topics in science classes,’ N’Shea says, ‘then they’re discussing them in English classes too. We used the science as a framework for our English lessons, and that was essential. Rather than teaching two disciplines with no dialogue, we created a bridge.’

This approach saw immediate shifts in perception. Dr Hussein Alibrahim, now a house officer in Kuwait, says his primary and secondary education was all in Arabic, and the foundation course, where English and science stood side by side, ‘was an advantage and a necessity. Skimming carefully through an article, identifying keywords, summarising, criticising, asking questions, and looking for the right answers are all skills that I learned for the first time in the foundation course and are skills I still use today,’ he added.

Edward Wilkinson

But the programme was not only useful for medical school. Alibrahim noted how it changed his day-to-day life as well. It taught him important lessons on punctuality and work ethic. ‘If you don’t learn [these things in foundation school] then maybe you’re in the wrong place,’ he notes.

With time, the team refined the course. After looking into the discrepancy between spoken and written levels of English, N’Shea and Wilkinson determined that the most probable reason behind it was a lack of reading by the students. Due to this, reading is now a core element of the course and is based on science topics to keep students’ interest piqued.

Now that the coursework has been implemented, positive results can already be seen. Students are so ready and raring to go that ‘sometimes they even want to take over the sessions,’ says N’Shea. ‘A student came up to me in class one time and asked to explain a concept to the others. It was such a dramatic shift.’ This has made it a joy to be in class, he adds, saying that ‘it became an active classroom. Students are totally immersed now.’ He feels that, through this course, the students are empowered ‘because they feel they can bring into the classroom all the things they know from science, but explore them through language.’ This way, ‘English is presented as a skill set to enable them to better achieve their goal in the career path of choice. It makes English less of an extra subject and more of a tool,’ he adds.

N’Shea, Wilkinson, and Stabile all agree that they will continue to perfect the programme. Currently in the works is a coursebook dedicated to developing listening skills. It will concentrate on areas such as note writing and identifying and differentiating words even when people speak with different accents. However, before the ‘listening book’ (as they fondly call it) is released, we will see the ‘reading book’, which will provide scientific passages for the students to read and be assessed on. All editions of this book will have the added bonus of a teacher’s book, meaning that the coursework can be taught by any teacher around the world, even if their knowledge of science is lacking.

With students communicating more, isolation is less of an issue and this is immensely beneficial. ‘We have to remember the dramatic shift that these students are going through,’ Stabile says. ‘They’re moving country, dealing with culture shock, all while fending for themselves for the first time in their lives, an adjustment local students do not need to make.’ This, along with the pressure that comes with a course you only get one chance to pass, is significant.

With students communicating more, isolation is less of an issue and this is immensely beneficial.

The fruit of their hard work is evident. According to research conducted by the team, between 2008 and 2015, 86% of MFP graduates progressed through Medical School. Moreover, the proportion of MFP students who repeat Year 1 of their medical degree is only 8.2% compared with 8.8% for EU (mostly British) students between 2014 and 2017. They also found that MFP students who started in 2010 and graduated medical school in 2015 achieved the same average grade over the whole five years as did local students in that cohort.

That said, all this work is not just about grades. Stabile says the team’s intentions go beyond seeing students pass exams. What they want to do is to ‘place them on a trajectory for success.’ And that is definitely a goal they are achieving, one year at a time.

  Author: Nicola Kirkpatrick

Maltese Medical Minds…ASSEMBLE!

Diseases and disorders plague humanity. They have the power to devastate the afflicted and those close to them. Globally researcher are fighting back. Recently, the Maltese branch of this international force came together at the 9th Malta Medical School Conference to present their most recent findings on matters from pediatrics and public health, to the minute mechanics of the molecular world that make us all tick. Outlined here are just two examples out of over a hundred presented on the day. Words by Scott Wilcockson.

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It’s all in the family

AlexandraFiott

Whatever you inherit comes from your biological family. Unfortunately, this includes disease. Talking about inherited conditions can make people anxious, making them unwilling to discuss the issue with their relatives. After speaking to a number of people my impression is that it seems taboo to discuss these things. People seem to feel that they will be stigmatised or treated differently because of a genetic condition.

A fear of social stigma hinders beneficial research. Research needs the collaboration of patients, since by investigating their condition researchers can in the long run develop a treatment or therapy. Not only that, but avoiding certain discussions means that relatives who might be at risk of developing the same problem would not be aware of it. If a condition is detected too late there might be very little that can be done.

It is very useful to discuss these matters with your family and speak to your doctor together. By building a medical family tree you can easily see who might inherit what. This way, your relatives will learn more about their health and then seek treatment. For example, a cousin might learn that she has an increased risk of breast cancer and would therefore attend screening sessions to catch the cancer before it spreads. Not knowing that something is there does not make it go away but discussing medical matters with your family could save a relative’s life.

“It is very useful to discuss these matters with your family and speak to your doctor together”

Scientific studies need family medical information. Scientific studies using family trees have already shown how useful this information is in identifying families with a high risk for inheritable cancers, like colon and breast cancer. Other research showed that families can benefit from preventative treatments against cardiovascular diseases like diabetes.

Local research has recently used this technique to find new genes, knowledge that can be developed for new treatments. The researchers were studying the genetic background of the protein which carries oxygen in our blood, haemoglobin. This protein switches from foetal haemoglobin to adult haemoglobin 3–6 months after birth. People with thalassemia have a problem with the adult version. Therefore, by studying local families that naturally cope well with the disease, they discovered the KLF1 gene that compensates for the malfunctioning adult protein by raising foetal haemoglobin levels. This was only possible with the help of family trees.

Speaking to a doctor to prepare a medical family tree (pictured) is done in the strictest confidentiality. You may also create your family medical history on https://familyhistory.hhs.gov/fhh-web/home.action to discuss with your family and doctor. I believe that it is in our best interest, apart from being potentially beneficial to the rest of humankind, to help in the creation of our own family medical trees.

If you have any queries when your physician or consultant asks you to prepare a family tree feel free to discuss them rather than avoiding family trees.