Gender Bias in the Management of Patients Still Exists

TY - JOUR

T1 - Gender Bias in the Management of Patients Still Exists

AU - Mackey, Cassandra

AU - Diercks, Deborah B.

N1 - Funding Information: DBD has received funding personally from Janssen Pharmaceuticals, Roche, and ET Healthcare for consulting. She has received funding from Siemons for research work. DBD’s institution has received contract funding from Roche for industry related research. Funding Information: In this issue of Academic Emergency Medicine, Humphries et?al. report that females with cardiac chest pain and cardiac troponin levels above the 99th percentile are less likely to receive guideline recommended care for an acute coronary syndrome (ACS). By using strict criteria, the authors attempted to adjust for differences in presentation and adding to existing literature showing that gender bias exists even when objective criteria are used. Reading this article there was a temptation to scrutinize who was making the decisions. As an emergency department (ED) physician the decision-making process is often focused on the disposition and ED diagnosis and therefore discrepancies in outpatient treatments are outside of our purview. Using ED discharge diagnosis based on most responsible diagnosis codes, Humphries et?al. showed that ED physicians were more likely to diagnosis men with myocardial infarction. Gender bias in the diagnosis, management, and treatment of chest pain spans the entire spectrum of ACS. Studies show delays in the identification of ST-segment elevation myocardial infarctions (STEMIs) in women. Evan after a STEMI is identified, women have longer median door-to-STEMI activation than men. Women have also been found to receive fewer cardiac catheterizations than male patients, even while controlling confounders such as complaint, history, echocardiogram, and diagnosis. Further highlighting our role as ED physicians in this process, it has been shown that physician gender and experience influences the treatment and management of patients who present with chest pain. Physicians are less aggressive in optimizing risk factors for cardiovascular disease in women. A study by Napoli et?al. showed that male physicians were less likely to order stress testing in female patients in an analysis that assessed gender interactions between providers and patients after controlling for cardiovascular risk. The impact of gender bias has been demonstrated in many acute illnesses within the scope of emergency medicine. There have also been disparities demonstrated in treatment of women in ischemic stroke. Fewer women with ischemic strokes receive thrombolysis and those who do experience greater lengths in time to treatment. In a study examining time to initial antibiotic administration for severe sepsis or septic shock, women experience longer delays to care (Table). Unfortunately examples of gender bias can be found in numerous disease states. Limiting variance in individual practice through the use of protocols in the management of ED patients has been shown to be one mechanism to reduce bias. The use of a structured approach reduced gender bias in pain management when a strandardized analgesic protocol was instituted. A standardized method of risk stratification, such as the HEART score, might be able to overcome the inherent bias that exists in the evaluation of patients with ACS, by taking away subjective experiences and using objective data. The HEART score or HEART pathway is meant to reliably categorize patients who present with chest pain as high risk or low risk for major adverse effects. There is no mention of gender in the pathway allowing every patient to be treated equally based on presentation. Although at a quick glance, the HEART score appears to use subjective data in the description of chest pain, it does in fact give specific objective descriptors to determine low risk, moderate risk, or high risk. Another method for eliminating bias is to utilize checklists as clinical decision support devices. A necessary step in overcoming disparities in the ED is to acknowledge that a gender bias exists in emergency medicine at the physician level and therefore independent of any disease process or illness. In fact, data suggest that in an academic setting bias can be transferred from physicians to physicians in training. The vertical transmission of bias from teacher to student is concerning as it is an impediment to the elimination of bias in medicine. We in academic medicine need to evaluate our role in perpetuating this process. To aid in the avoidance and acknowledgement of bias, incorporating a tool such as the implicit association test (IAT) into physician education may be necessary. With this test, biases will become less implicit and unconscious, allowing physicians to reflect and change their practice of medicine. Furthermore, we need to recognize that the association of a risk of disease with a race, gender, or ethnic association in itself may result in implicit bias. It is therefore important to contemplate if there is a need for consideration of gender in a patient's history. For example, it is reasonable to consider gender when deciding if a patient is at risk of coronary disease based on their physical examination and history. However, once an electrocardiogram is obtained and it shows ST-segment elevation in an anatomic distribution there is little need for consideration of gender in the management of the patient. The relevance of a patient's gender diminishes as objective data is obtained. The study by Humphries et?al. adds to the body of literature that gender bias exists. It is time to make a change. Our recommendations are to recognize that gender bias exists in emergency medicine, participate in the IAT to uncover the implicit bias, and include gender in decision making only when it is necessary. In the area of ACS, we are hopeful that further incorporation of decision tools or checklists may further address this problem. As suggested by Humphries et?al., to eliminate bias we need to challenge ourselves to not include gender in medical decision making when objective data can drive care. In the future when evaluating a patient with chest pain and elevated troponin levels we need to ask ourselves ?How should we manage this patient with chest pain and an elevated troponin?? DBD has received funding personally from Janssen Pharmaceuticals, Roche, and ET Healthcare for consulting. She has received funding from Siemons for research work. DBD's institution has received contract funding from Roche for industry related research.

PY - 2018/4

Y1 - 2018/4

UR - http://www.scopus.com/inward/record.url?scp=85044238603&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=85044238603&partnerID=8YFLogxK

U2 - 10.1111/acem.13394

DO - 10.1111/acem.13394

M3 - Comment/debate

C2 - 29479769

AN - SCOPUS:85044238603

VL - 25

SP - 467

EP - 469

JO - Academic Emergency Medicine

JF - Academic Emergency Medicine

SN - 1069-6563

IS - 4

ER -