April 29, 2016

"Its All in Her Head: A Case Study in Possible Sexism in Medicine

My research project on the factors causing diagnostic delays in patients seeking medical help has thus far yielded a plethora of information about gender bias, an increase in mis-diagnosis of symptoms being psychogenic in origin and how these two items in particular come in to play within medical systems under pressure to cut costs and caseloads.

Health care professionals at the Society to Improve Diagnostic Medicine add to the above mix, studies implicating doctor over confidence and cognitive error:  www.improvediagnostic rights.org. There is some sound advice for patients from this organization on how to prepare for appointments and how to ask the right questions of a provider. Glancing at these recommendations, however, I wonder at how effective such exhortations might be within the context of bias based upon race, gender and age and a medical climate which makes questioning a patient’s credibility so easy.

By way of illustration on how all these factors might come in to play, I found a convenient case study through a recent post by an allergy clinic in the Great Britain.


In his post, we read about a case of "psychosomatic" allergy. A female patient comes in to a doctor’s office. He identifies her as "flustered looking." She claims that she is getting allergic reactions from her dog. The doctor then proceeds to inform us that the woman "admits to" a history of anxiety. Despite these initial observations, he proceeds to test, via blood and skin prick test analysis, allergy to pet dander. The negative test results are conclusive: the patient is assuredly not allergic to her dog.

Not convinced by negative test results and reassurance that there is nothing physically wrong with her, the patient reportedly consults a doctor in "alternative" medicine who advises her to give up her dog. She does so and reports to the allergy clinic that her allergies have ceased. Her reactions are attributed to "New Age Clap Trap."

The doctor most likely came to his conclusions based upon the analysis that "symptoms do not match results" a phrase invoked to allow practitioners to quickly and easily ascribe a patient’s symptoms as most likely psychogenic or some other "clap trap." But what if symptoms did not match results because the right results were not ascertained? Lets examine the case once more within the context of what might have happened with bias removed and an intelligent, inquisitive mind added.

A patient comes in to an allergist’s office. Instead of being judged immediately as "flustered looking," a more professional approach is applied and a calm and dispassionate medical history is taken. The immediate label of "flustered looking," is, of course, for the benefit of readers. In logic this is called "poisoning the well." It is a well known technique for prejudicing an audience against a person by casting aspersions against a person’s character or demeanor in order to discredit his or her story. It is a very effective tool for people not inclined towards rational discourse and easily accepted by a gullible public.

To proceed again with our imaginary doctor with his own head in science rather than "clap trap," he takes a dispassionate history. In the original case study the patient "admits" to anxiety. How exactly, does a patient "admit" to this? Did she have some kind of inquisition style confession extracted? So our rational doctor dispenses with this "clap trap" and instead asks the patient about her history of allergic reactions to various substances, takes a family history of allergies and comes up with a diagnostic plan. He does the requisite blood tests and skin prick tests. They are negative. The patient is not allergic to our dog.

But our new compassionate, scientific, doctor does not dismiss the patient. Instead, his curiosity is aroused." So he questions the patient again in an unbiased, rational and scientific manner. 
"Do you notice symptoms worse at some times rather than others?," he asks.  The patient responds in the affirmative.  "Tell me when those times are and what happened," he continues. 
The woman thinks about it a minute and says, "When my dog goes for a romp in the field behind my cottage, I sneeze and have watery eyes upon his return."
"Any other times?" he asks.
"Well... " the patient continues,  "When I picked him up after his bath at the vet's, my hands and arms broke out in a red, itchy rash"
"I wonder," the doctor then thinks to himself, if the patient is not allergic to her dog but something on her dog. He proceeds to run tests on other environmental allergies as well as tests for chemical allergies. Several allergies to grasses and pollen are found. Two chemical allergens are found: urea and paraben, both chemicals commonly used in pet care products. The patient is given some antihistamines is reassured, but this time the reassurance is based upon science rather than prejudice. She is advised to bathe her dog in paraben and urea free soaps only and to check the contents of flea and tick powders before using. She can keep her little dog. I do so love happier endings.