Tuskeegee syphilis experiments
on black Alabama sharecroppers. The British Ministry
of Defence's nerve gas tests on its own soldiers in
the 1950s. The CIA's LSD experiments at McGill in the
1960s.
Conducting medical research without
a participant's knowledge has a long and undistinguished
history. The research listed above strayed way beyond
all bounds of ethics and has generally made scientists
wary of doing anything to patients without informed
consent.
So the fact that the March 11 issue
of the Canadian Medical Association Journal carries
a major study in which participants, at the moment of
being studied, were not told they were being studied
may surprise and alarm you. Especially when you hear
that the subjects being kept in the dark weren't patients,
they were doctors.
The study's findings — that
physicians were as much as 22 times more likely to refer
men for knee replacement as women — and methods
have the medical community crying foul.
GENDER
OFFENDERS
When surveyed, physicians generally say that they treat
both sexes equally. But the statistics clearly show
that not all procedures are carried out equally.
Total joint arthroplasty is the
gold standard for clinically-proven arthritis with severe
symptoms and disability. In Canada, this procedure is
performed more often in women than in men, but then,
far more women than men suffer from severe arthritis.
A survey of 48,000 people aged 55 and older in two Ontario
regions, published in NEJM eight years ago, found
that among patients who were good candidates for hip
or knee arthroplasty, the "unmet need" for surgery was
three times higher in women.
One of the authors of that study,
Dr James Wright, an orthopedic surgeon at Toronto's
Hospital for Sick Children, led the current study, to
find out what lay behind this disparity. Could it be
gender bias? Doctors almost always deny gender bias.
So how to test that hypothesis? Enter the undercover
researchers.
Two patients were recruited, a
man and a woman, with clinical symptoms of moderate
knee osteoarthritis as close to identical as could be
found. Both were good candidates for arthroplasty. They
were extensively coached on what to say when they visited
38 family physicians and 33 orthopaedic surgeons around
Ontario, to ensure that their consultations were as
similar as possible. "We even surreptitiously videotaped
them, during a consultation with a doctor who knew about
the study," says Dr Wright, "just to be sure there was
no major difference." Neither patient was told the purpose
of the study.
The study was not completely lacking
in informed consent. Physicians were approached at the
outset of the trial, and asked if they would participate
in research that used undercover patients. At the study's
end, the participating physicians were told the purpose
of the research and given an opportunity to withdraw
their data if they wished. Four did.
'HERE'S
SOME PILLS'
The data provided strong confirmation of the researchers'
hypothesis that gender bias was at play. Overall, 42%
of physicians recommended total knee arthroplasty to
the male but not the female patient, and 8% of physicians
recommended it to the female but not the male patient.
Family physicians were twice as likely to recommend
arthroplasty to only the male patient as they were to
recommend it to only the female patient. Orthopedic
surgeons were no less than 22 times as likely to do
so. "Overall, it closely matched our survey findings
- that unmet need is three times higher among women
than men."
"It was amazing. Some doctors said
'here's some pills' and gave me a prescription," the
female patient, Dorothy Aungier, 72, told CBC News.
"One doctor said 'just walk on grass.'"
Even women physicians showed a
gender bias towards the male patient, though there were
not enough women doctors in the study to make that trend
significant. "I'm not really sure what to make of that,"
says Dr Wright.
BIAS
BASIS
So why would physicians favour men anyway? "Just asking
them why isn't all that productive," says Dr Wright,
"because usually, they're genuinely unaware that they're
even doing it. But I think there's a subconscious perception
still that women tend to be more descriptive in talking
about their symptoms, while men are more matter-of-fact.
I think the belief that men are more stoical is fading,
yet it seems their symptoms are still taken more seriously."
One alarming possibility is that
doctors are hearing, anecdotally, that women benefit
less from surgery. But women's disease is typically
more advanced at surgery, because their need is unmet.
This opens the prospect of a vicious circle where women
do poorly from surgery because they're referred too
late, leading doctors to doubt the benefits of surgery,
leading them to refer women even less.
The physicians who came across
as the most biased in the study — orthopedic surgeons
— aren't convinced there's a problem. "You know,
I personally don't think as a group of surgeons that
we are going around biasing based on gender," Halifax
ortho surgeon Dr Michael Dunbar told CBC. "You know,
I really don't think that is happening."
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