Episode 57 - Anat Biegon

Why Do Women Go to the Doctor Twice as Often as Men? Bias and Education about Women’s Health

Theme: Women and Medicine

Published: 19 April 2024

Summary
In this SCAS Talks episode, Professor Anat Biegon discusses the critical issue of gender bias in medicine. Highlighting significant sex differences in drug response, disease presentation, and diagnosis, Biegon reveals how women receive suboptimal healthcare due to research predominantly focused on men and ingrained biases. She shares her experiences developing a medical school course to address this disparity, emphasizing the importance of incorporating sex-specific research and fostering critical awareness among future healthcare professionals. Biegon's work underscores the urgent need for gender-based medicine to ensure equitable and effective healthcare for all. The podcast includes a discussion of her current research project, expanding this vital educational intervention to a wider audience, promoting a future of more inclusive and effective medical practices.

Keywords
Women's health, gender-based medicine, bias, sex differences, clinical trials

Suggested Link/s
Personal website: https://renaissance.stonybrookmedicine.edu/radiology/anat_biegon External link, opens in new window.

Transcript of the Episode

Anat Biegon 00:10
Women are getting poor medical care relative to men, and the implications and the results of that are that women are much more likely than men to suffer adverse effects from drug treatment, to have poor outcome, including death from surgery, that they are often late diagnosed, which again leads to misdiagnosis. It means that when they come to treatment, they are in a more advanced stage of disease, and the outcome is worse. On the social level, you have half of humanity, which is getting medical treatment that was optimized and developed for the other half.

Natalie von der Lehr 01:01
Welcome to SCAS Talks, a podcast by the Swedish Collegium for Advanced Study. My name is Natalie von der Lehr, and in this episode, I talk to Anat Biegon, Professor of Radiology and Neurology at the Renaissance School of Medicine at Stony Brook University. She is a fellow within the program of Natural Sciences at SCAS during this academic year, 2023/2024. Anat Biegon studies sex differences and hormonal effects in the brain and her education and outreach activities include creating and teaching a class on issues in women's health and gender based medicine. And this is also the topic for today, since this is the first episode within our theme, "Women and medicine". Welcome to SCAS Talks and the studio, Anat.

Anat Biegon 01:54
Thank you.

Natalie von der Lehr 01:55
Would you like to say a few more words about yourself?

Anat Biegon 01:58
I was always interested in the brain since early childhood. And then when I got to university, I started out with chemistry, because I thought chemistry of the brain is very important. And then I went into biochemistry and pharmacology, and I became aware, when I was becoming a researcher, that they are a lot of diseases, disorders that are more common in women than in men, and also that they are big differences, sometimes in the response of men and women to medications for the same disorders. So the disorder that caught my eye was depression, because depression is more common in women than in men. That the antidepressants used at the time when I was graduate students were less effective in women than in men. So I decided to start my research by trying to find the answer to the question of why are women more likely to have depression, and why they have a worse response to antidepressants, and I started my work in a animal model. So I had male and female rats, and I decided I will manipulate their hormones to see whether these differences may have something to do with hormones in the brain. Manipulating hormones basically means surgery and injection of drugs. So I had to anesthetize, you know, put all of my animals to sleep. And I just asked my mentor for the drug and dose that I need to use to put them to sleep for surgery, and I used the recommended dose, and all of my females died. So this was a very rude reminder, oh yeah, males and females are very different, and it can mean life and death. This was sort of my strong introduction to many years of research trying to analyze and discover and quantitate differences between males and females, men and women, that have medical and clinical implications.

Natalie von der Lehr 04:04
So how come your supervisor told you the wrong dose?

Anat Biegon 04:08
Oh, they just didn't know what the dose for female was, or that there is a different dose for females, because no one was using females. When I started my research, I was the only graduate student in the group who was a female, and I was the only person in this whole big research institution that used females as research subjects. So there was a small department in the institute that specialized on research on endocrinology, reproductive function, and they used females, but everyone else used exclusively males. It was considered okay to use males as a model for any species at the same time and for the same reason, I guess that it was considered okay to only use men in clinical trials. I'm talking about the 70s. And I started my PhD when it was 1976 and at the time, it was not only uncommon, it became illegal, at least in the United States, to include women of reproductive capacity, women who may become pregnant, which is anyone between 15 and 50, in clinical research because of the possible effect on a possible potential fetus. So no one thought about it, and no one knew. So I had to discover the hard way that actually the dose for females is about one half of the dose for males, if you want them to sleep rather than die. Actually, it took almost more than 30 years before this awareness was reached in human studies. Actually in the same field, in the field of anesthesia, it became apparent really recently, a few years ago, that drug for a sleep medication called Ambien, that was developed sort of in men and women, but the results were never divided separately men and women, so it was considered safe, that it was very likely, two to four times more likely to cause dangerous to lethal complications in women, specifically because, as you know, you take sleep medication, you wake up in the morning, you get in the car, you go to work, and then women were getting into this car accidents at a very high rate, in getting you know injured or dying because of these accidents. And this became apparent way after the approval of the drug, when reports were coming in about the adverse effects of a newly approved drug. And then the FDA conducted an experiment where they brought men and women into the lab, and they measured the levels of the drug in circulation in the morning, and also had everyone do a simulation driving test, and the women were failing the simulation test, and the drug levels in their circulation were two times higher than in men, exactly like in my rats. This is what I found. You know, I looked for the drug levels, and it turned out to achieve the same level of anesthesia and the same level of drug in the circulation you had to give females one half of what you gave males. So this was rediscovered in people more than 30 years later.

Natalie von der Lehr 07:44
When you talk about it, it seems so logical that if you have more than half of the drug still in circulation, then of course, you will be drowsy and you can get into an accident.

Anat Biegon 07:55
The logical chain from the finding to the consequences is trivial, but to find that the levels are different in women, you had to ask the question. You had to measure them in men and women and separate the results. Rather than, you know, you measure in everybody, and you calculated a mean, and you said, you have to give so much to get so much, plus minus, whatever. Just, you know, separating men and women, or males and females, or including women, is a novel concept. I mean, it shouldn't be novel. To me this looks very logical, too. You know, if you come from science, if you know something about genetics and men and women, males and females among mammals are different animals. The genetic difference is very big. It's a whole chromosome. If you're looking at genetic differences among, for example, races and ethnicities, which are very popular research subjects, they are minuscule. There are very few gene configurations that are more common in people of different races, ethnicities, but here we're talking about the whole chromosome. It's a very large difference.

Natalie von der Lehr 09:06
And half of the world population.

Anat Biegon 09:08
Yeah

Natalie von der Lehr 09:10
Now this is the first episode within our theme, women in medicine. What do you think makes this topic so important?

Anat Biegon 09:17
I guess the yardstick that's indisputable is death, is life and death and just behind that quality of life. So we just look at it, if we focus our gaze on this question of, you know, women's medicine versus men's medicine, women are getting poor medical care relative to men, and the implications and the results of that are that women are much more likely than men to suffer adverse effects from drug treatment, to have poor outcome including death from surgery, that they are often late diagnosed, which again leads to misdiagnosis. It means that when they come to treatment, they are in a more advanced stage of disease, and the outcome is worse. On the social level, you have half of humanity, which is getting medical treatment that was optimized and developed for the other half, and they suffer the consequences. So there's a lot of unnecessary deaths and a lot of unnecessary suffering because of this historical neglect of the fact that men and women are not the same, genetically, physiologically, anatomically and and in many other ways, and just whatever sauce was developed for the goose is given to the gander and vice versa. So I think it's hard to exaggerate the importance of this topic.

Natalie von der Lehr 10:58
And one of the diseases which is a strong example for these sex differences, is actually cardiac disorders. I only learned about this recently. Could you tell us more?

Anat Biegon 11:10
It was a work few decades back. It was the work of a few women cardiologists, pioneers in the field, that form the basis for the whole field of gender based medicine. Because awareness of the fact that women are more likely to have some common mental disorders like depression and anxiety, we've known this forever, but this never caused people to question the way drugs are developed or diagnosis are made because we had an answer for that going back to Freud. It's in their head. You know, women are more likely to be depressed and anxious because they're hysterical. So the field of gender based medicine never happened because of depression and anxiety. But when these women cardiologists started looking at the presentation, for example, of a heart attack in men and women, and then they dove in into the anatomy of the cardiovascular system, the anatomy of major blood vessels leading to the heart and the composition and pathological behavior of plaques in the cardiovascular system, in these blood vessels of the heart that lead to blockade and heart attacks, myocardial infarcts, etc, they found very large differences between men and women in all of these - the size of the vessels, the response of the vessels to pathology, etc. And this was very hard to dismiss as being in women's head. It was in their heart. And it was very objective and measurable. You could take specimens for small term from arteries and dissect them and look at the composition of flax, they discovered these very large differences in the cardiovascular system of men and women, which sort of led to explanations for why women were so unlikely to be properly diagnosed with a cardiovascular disorder for years, and why, when they did have a cardiovascular disorder or even a heart attack, their outcome was so much worse. So the cardiovascular health is one of the fields where you see all of it. Because what the field of gender based medicine basically investigates and claims is that your biological sex as well as your gender, have cardinal influences on everything that has to do with medicine. Which includes prevalence of disease, which has to do with presentation of disease, both of these have to do with diagnosis, how likely you are to diagnose the right disorder in a person has to do with what you know about the prevalence. So for example, we all know that heart attacks and cardiovascular disorders are more prevalent in men than in women, so they're less likely to be diagnosed in women, even though cardiovascular disorders are the leading cause of death in both men and women. So there is a difference in prevalence. Let's say there is even twice as many heart attacks among men than among women. You're still talking about hundreds of millions, and it is still the leading cause of death among women. So the prevalence is influenced by sex and gender, and the presentation, the way a heart attack looks is different in men and women. Men have the classical heart attacks that you see in the movies, with chest pain on the left side radiating to the left arm and fainting and very dramatic. And in women, as often as not, very often in women, these may be symptoms, or these symptoms may be absent altogether, and what they feel is nausea and difficulty in breathing and the pain in the jaw, things that have never been associated with the presentation of a heart attack in men. But when you start looking and you look at women with documented, who get documented heart attacks, you see that what brought them to the emergency room or what brought them to the doctor were very different symptoms. So by now, this is well enough established that they even teach it in medical school. But if you're a physician who graduated from medical school 10, 20, 30 years ago, it hasn't penetrated far enough. So there is this difference in presentation, and then there is a difference in the underlying pathology, which also means that the drugs that are given for cardiovascular disorders in men are less effective in women because the disease pathology is different. And actually the pathology that is more common in women, which is called small vessel disease, doesn't really have very good pharmacological treatment. Then, of course, you have a difference in outcome, and then you add to it, this bias that is reflected in physicians thinking it's less likely that a woman really has a heart attack, not taking women's reports of their symptoms seriously. This is due to gender. If you haven't been born a biological woman, if you convincingly look like a woman, you will get the same bias. So this is yet another contribution to misdiagnosis and poor treatment.

Natalie von der Lehr 16:58
Between 2016 and 2022 you have taught, and in fact, created a class on issues in women's health and gender based medicine, and this was offered to medical students. The goal of this class was to make medical students more aware of women's health. Can you tell us more about this class?

Anat Biegon 17:19
So in this class, I started with basic science lectures by PhDs about the genetic differences between the sexes, metabolic differences, differences in body composition and anatomy that can lead to different medical manifestations. And then I had physicians, clinicians who specialize in different fields talk about disease manifestations and sex differences in their fields, which were, you know, I had a neurologist who specializes in multiple sclerosis talk about sex differences in multiple sclerosis, this is a relatively common autoimmune disorder which affects women at two, three times the rates that it affects men. So it's a poster child. And then we had lectures about cardiovascular disease, and we also had lectures about bias, implicit bias. How do you recognize bias? Who has biases? Don't be ashamed if you have a bias, it doesn't make you a bad person. So I taught this class to 24 students at the time, because I thought, and this was proven to be right by the students' responses to the class, that if the students do their own research, it will be much more compelling and convincing to them than if they just hear us talk about it. So the class was really like three parts. 1/3 of the lectures were background lectures by PhDs. 1/3 were clinical lectures by physicians, and 1/3 was we told students, go out there and find the topic that interests you personally, that has something to do with medicine and something to do with sex differences, and do your own research and come back and report to the class. So 1/3 of the lectures were actually given by students in groups of two or 3, 20 minutes each, where they chose the topic, they researched the topic and they reported on it. They taught the class about the topic, and they had to entertain questions about it.

Natalie von der Lehr 19:25
And then you also did an evaluation of both what the students thought about this class and what they had learned. What were your findings there?

Anat Biegon 19:35
A lot of the students said that this was interesting, that they learned things that they have not learned in medical school, they have learned things that they should have learned in medical school, that they think this class should be part of the curriculum and not an elective, selective or small group at the time. We also thought that we have to devise a way of evaluating the class in terms of knowledge learned, which is not included in the general questionnaire because it was the first class of its kind. So how do we evaluate whether the students really learned something about gender based medicine and women's health? So I decided that because the actual diseases and medical conditions that were discussed in different years and semesters were not necessarily the same, that what we could look for rather than specific knowledge like, you know, do you know how many women versus men have thyroid disease? Because one year we taught thyroid disease, another year we didn't have a physician to teach it, so we didn't have it. So I found in the statistical literature about utilization of medical infrastructure in the US, for example, the Center of Disease Control, that women are twice as likely to go to the doctor or to be hospitalized, especially, you know, in their reproductive years, women, not little girls, than men. And I thought this could be a good hook. I will ask the students in the beginning of the class: "Why are women more likely to go to the doctor than men"? And because they are medical students, and they know some things, they will say, well, women are the ones who may become pregnant and give birth, and they have menstrual cycles. So there is this whole reproductive health package that women have and men do not have at all. So this could be a reason why women go to the doctor more, and then I will teach them about the autoimmune disorders and the side effects of drugs and the bias and all of the other things I teach in the class, and I will ask a question again, and if we're successful and they learned, then they will say, oh yes, women are more likely to have, you know, reproductive health issues, but also they live longer, so they're more likely to have old age diseases, and they're more likely to have autoimmune disorders which are chronic. So this will be the proof that we taught them something. And to my big surprise, from the very first class in 2016 until the end in 2023 the students, absolute majority of the students had only one response to the question. The reason women go to the doctor more is because it's easy for them to ask for help. And it's actually, the problem is the man. It's the men who go to doctors less because they are conditioned to be strong and take risks and for them to go to doctor is admission of weakness, so they are the ones not going to the doctor, and this is what creates the sex difference in utilization of health. And you know, there are many variations on the theme, so some students added things, like, women have more time, so they go because they work part time, so they go to the doctor more. Or women have to go to the doctor with the children. So there are a lot of subtleties to this description, but what they all have in common was that they had nothing to do with medical need. They had nothing to do with health condition, which is why I thought it was surprising, because if you tell people you know, old people are more likely twice. It's the same statistics. You know, people over 65 are twice as likely to go to the doctor than people under 45, why is that? The answer will be, well, they're sicker. If they're older, they have more you know, there are all of these old age disorders that only happen to old people, Parkinson, Alzheimer's, etc, and cardiovascular disease increases with age, and cancer increases with age, so they need more medical treatment, so they go to doctors more. And I thought this is trivial, that if I tell you that women go to doctors more, it's because they have more medical needs. And instead, I got this stereotypes. On the good side, I asked the same question at the end of the class as planned, and from 80% saying the reason is, women are weak and men are strong, it went to 30% and none of the students named, even the ones who still mentioned this as a reason, and it could be a minor contributor to the sex difference, they added other reasons. So even the ones who still said men do not want to go to the doctor, it's a reason for the differences. They had other reasons as well that came from what they learned in class. So on the good side, it means that you can theoretically counteract the prejudice, and you counteract the bias by showing people that they have a bias and supplying them with knowledge. You can actually hope that you're sending them into the world better equipped to deal with women's patients, and again, in the narrative portion of the responses many of the students said things like this class taught me I have to listen to my patients. It will teach me to treat my female patients differently. I will be looking before prescribing drugs whether this drug was actually tested in women. So there is a theoretically direct path between reducing or counteracting the bias and supplying the knowledge and better medical treatment for women, although we don't have the proof yet.

Natalie von der Lehr 25:33
Now, while you're at SCAS, you are conducting a study which is sort of a mini version of this course in the US. What exactly are you doing?

Anat Biegon 25:43
In my mind, it's not a minimal version, it's a macro version. What is mini is the intervention. I'll explain what you mean. So my experience in the US comes from a single school, single medical school, in a single country. To be able to generalize this. We need to go to more places, more schools, etc, and perhaps enlarge the number. Because of the limit on the class size, we have taught the class to about 150 students total. So what I'm doing here, is I found collaborators in Lund and in Uppsala who teach classes to medical students, to nursing students, to midwifery students and to students of biomedical sciences. So we are going to recruit at least 600 students of different health professions. So it's, again, not just medical we are enlarging, and we're going to ask them the question.

Natalie von der Lehr 26:45
And the question is?

Anat Biegon 26:47
Why are women twice as likely to go to the doctor? And then we're going to give them, possibly online, depending on the exact population, a one hour lecture that summarizes, hopefully, everything we had in the class, because it is more practical. You know, we cannot get a class into every medical school in Sweden.

Natalie von der Lehr 27:10
That's what I meant with the mini.

Anat Biegon 27:11
Yeah, it's a mini intervention for a macro study. It's still not macro, you know, my ambition is to do it everywhere in the world, etc, etc, and among physicians. But right now, what I manage to get together is access to medical students, nursing students, midwifery and medical science, where we're going to expose them to one hour concentrated lecture that describes bias and describes the sex differences in different medical fields, and then asks the question again, so let's see how common this bias is and whether we can address it with a short intervention, and hopefully, if we can show that the bias is prevalent even in a progressive country like Sweden. And that you can address it with a practical size intervention. Perhaps it will be taken up by other educational institutions, and we can do some good in the world.

Natalie von der Lehr 28:16
But what have you found so far yet.

Anat Biegon 28:18
I piloted this one hour intervention in three populations since I came here to Sweden. So one of them is my colleagues here at SCAS, who are not Swedes, necessarily. There are a few Swedes, but there are people from all over the world, and they are older than medical students, and they are all very highly educated, although mostly in humanities, and 60% of them gave the same answer as the medical students. So the group size is not enough to say whether it's significantly less, but it's it's less. You know, I had more people in this group who gave answers that were not stereotypical, like women live longer, they're more likely to have age related disease and they have reproductive issues. So there were 40% of the responders actually gave answers that were related to health. But 60% had the same answers as the medical students. And then I also did this with a group of postgraduate students, again from Sweden and other countries in Europe, who specialize in women's health, and it was 80% and then I did the same with the midwifery faculty and graduate students - 80%. And they were very suprised. But again, the good news was that among the midwifery professors and students who answered the question, listened to the lecture and answered the question, again, it went from 80% to zero. So I have a good feeling about this And these were Swedes. It's interesting that when I was telling colleagues here about my pilots and the whole project, they say, well, it's not going to be like this in Sweden. And when I tell them, well, it's it was the same. "But these people are not Swedes. They're from other places." And again, I don't think this is like a badge of shame. No one should be ashamed of having a common bias in the lack of any information to counteract it.

Natalie von der Lehr 30:33
So you're a fellow at SCAS right now during this academic year, and you're a fellow within the natural sciences program. What is your experience of the multi- and interdisciplinary research environment so far?

Anat Biegon 30:46
Oh, I think it's a wonderful thing. I don't know where, how come I didn't know about SCAS earlier in my life. The natural science is a relatively new addition to SCAS, traditionally focused on humanities. I think, that the basic idea of SCAS and the mixing of natural sciences with humanities, it's a gift. It like exercises your brain muscles, you know, you're putting together people who would never spend 20 minutes talking business to each other, let alone an hour a day every working day, because part of the SCAS routine is that we are all expected to have lunch together every day. And usually we sort of rotate tables a little bit, so by the end of the semester, you have had lunch with historians and experts on English literature and social science people and political science people. You learn so much, and sometimes you teach a little. And the spirit is very collegial, which is again fantastic, because I think, you know, it's relatively recent in my long career in science. But there is less and less collegiality in academic institutions nowadays. People are encouraged to compete against each other, rather than to collaborate with each other. But you know, if you're sitting a table and you are a English scholar and the other person is a political scientist, they're not your competition, and they're from a different discipline. So collegiality, which I think is basic human drive, comes to the surface, and people help each other with ideas. It's very refreshing and very helpful to actually try your ideas on people who are complete outsiders, because the outside look is a fresh look. It's not inundated with all of the dogmas that got instilled into your head because you've been in this field for too long. The seminars that we have here, which is another SCAS activity. You know, every week we have a seminar presented by other fellows. They are brilliant. People are smart as devils. You know, they're so smart, and somehow everyone is also a good speaker, so they can communicate ideas from different fields. This is pure intellectual time, the world of ideas driven by curiosity, it's great.

Natalie von der Lehr 33:27
Thank you very much for talking to me and to our listeners, of course.

Anat Biegon 33:35
Thank you. It's been a pleasure.

Natalie von der Lehr 33:39
And thank you for listening to SCAS Talks, a podcast by the Swedish Collegium for Advanced Study. In this episode, I have talked to Anat Biegon, Professor of Radiology and Neurology at the Renaissance School of Medicine at Stony Brook University. Anat Biegon is a fellow within the program of Natural Sciences at SCAS during this academic year, 2023/2024. And this was the first episode in our theme "Women and medicine". And we have talked about the importance of recognizing sex differences in different diseases, bias and education of health professionals in order to increase awareness about women's health. SCAS Talks features a broad variety of topics, which is a reflection of the multi- and interdisciplinary research environment at the collegium. We are sure that there is something of interest for everyone. Tune in, find your favorite topic, or surprise yourself with something new. As always, we are very happy if you can recommend SCAS Talks to your colleagues and friends. Subscribe to us and you won't miss any new content. SCAS Talks is available on podbean, Apple podcast, Spotify and most podcast apps. I would like to thank Anat Biegon once again for talking to me, and thanks to you for listening. Bye for now.

Transcribed by https://otter.ai