Friday, 25 May 2018

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Sexist Rheumatology

Men are Better & Easier to Care For – The Pro-Bro Stance – by Jack Cush, MD

Men are like dogs. What you see is what you get. Aside from the hairlines and sizes, there is not much variety. When they don’t fit this mold; they are usually incarcerated or labeled a metrosexual.

The topic of who is the better patient or consult came up last week.  It was after a particularly bad run of new consultations wherein no one had any real rheumatologic diagnoses. They either had meaningless abnormal labs, soft tissue ailments or needs that should not be addressed by a rheumatologist.  The fact that most were women was lost on me, until the next patient - a middle aged man appeared.  Before I walked into the room, I thought, “oh no, more of the same”, only to find out that he may have reactive arthritis!

A light bulb went on and I after came to the realization that men are usually better patients for several reasons.

  • Disorders that affect men are the ones that I’m good at and definitely want to see – AS, spondyloarthritis, reactive arthritis, gout, and OA of the hip or knee.  Conversely, estrogen dominant disorders are pestered with voodoo and misdiagnosis – multiple sclerosis, lupus, fibromyalgia, thyroid disease, scleroderma and Ehlers-Danlos syndrome, to name a few.
  • For a male to get an autoimmune or inflammatory diagnosis usually reserved for women, they have to mount enough disease to overcome the gender bias.  This is explained by the Carter effect that says multifactorial polygenic disorders can overcome a sex preference, but you need to have a greater load of susceptibility genes to surpass the sex bias.  For instance in lupus, they have to have genetic (e.g., Klinefelters) or immunologic hyper-expressions that lead to manifest lupus.  When this happens they tend to have more severe manifestations of disease.  This is cool by me as I am definitely up to the challenge and well able to diagnose and care for them.
  • Men are monosyllabic, no-nonsense consumers of healthcare.  If they are going to make the effort to get off the couch and go to the rheumatologist, they must have clinically worrisome disease.
  • Women need to be listened to; men prefer the quick visit. Women want to negotiate the merits of weight taking and BMI calculation and go straight to the exam table. Men are looking for a comfortable seat and an end of visit lollipop.
  • Lastly, men are incapable of complexity. Hence, one patient, one diagnosis, one complaint and one prescription will suffice for most males.  When this formula veers to the complex, there’s usually a woman in charge.  Everyone knows that behind every great man is a woman telling him he’s not so great (attributed to Harrison Ford).

I know that the numbers dictate that women are more likely to have autoimmune and arthritic disorders.  This doesn’t mean I’m lazy (or simple, or monosyllabic) or prefer to see fewer patients by restricting my practice to just men.  I’m up to the challenge of autoimmunity and estrogens influence; I just think it’s easier when it’s a guy thing.

Women are not bad patients, and neither are men. Both are equally capable of noncompliance, nonadherence, polypharmacy, medication/narcotic misuse and not paying their bills.  Choosing one sex over another does not guarantee better patient behaviors. But choosing men reduces the mystery and ups the certainty. 

Why Women are Better Patients and Why We Live Longer than Men - by  Kathryn Dao, MD

My partner, Jack Cush, MD decided to stand in front of my workspace last week with a flush to his face and a crazed look in his eyes. He was very excited to announce that the patient he had just seen is a male patient with real disease!  (This begs the question of what real disease is.)  

He had been burnt by too many cases of”voodoo diagnoses”.   He said he was writing a blog on why men make better patients and challenged me to give a rebuttal. . In fact, he started writing the introduction to my blog, “Men are Bedouin nomads In search of a prescription…”  Aside from my confusion about nomads and gonads, I chose to declare why women really are better patients. 

So the following list is a tribute to greatness of my female patients (and for the males who support them)….

  1. Women are tenacious fighters. They won’t give up until they get the right diagnosis and right treatment plan. They will present to the doctor earlier.  Remember all the early RA studies (ERA and VERA trials)? These studies taught us that early diagnosis, early treatment resulted in better prognosis and a chance for remission. Guess what? Most of the subjects enrolled were women!  These are the patients who presented early to the doctor with their symptoms.  When men go to the doctor, it’s bad; the barn has burned down and the horse is long gone.
  2. Most autoimmune, inflammatory rheumatic diseases affect women during their child-bearing years.  Not only do women have to worry about how to manage their diseases, but also they have to juggle pregnancy, lactation, children, and their husband’s health (just like the quote, “Ginger Rogers did everything Fred Astaire did, except backwards and in high heels”).
  3. “Medical adherence” is a habit to most women whereas most male patients (especially male doctors who are patients <ahem, Cush>) find the concept foreign.  Men often would need to be gently reminded at every visit to take their medicine, to wear their sunblock, to get their labs drawn, and to come to the next appointment.  Women know what has to be done and do it. This plays out in a 2006 study concluding women with gout were more likely (OR 1.36, 95% CI 1.11 to 1.67) to receive surveillance of serum urate level compared to male counterparts (L R Harrold, et al. 2006  http://bit.ly/2ETkfYI.)
  4. Men are monosyllabic and incapable of processing complexity. One of the most valuable lessons I learned in medicine is to give 1 diagnosis and to avoid prescribing more than one prescription at a visit …to a man. While you just had diagnosed him with rheumatoid arthritis, and although you suspect/observe chronic hypertensive disease, obstructive sleep apnea, and squamous cell skin cancer and notice his lack of vaccinations per current guidelines—resist the urge to address these issues in one visit.  However, if you must do so because these issues are urgent and cannot be delayed, get his wife on the phone.  Most men recognize their limitations and will have the foresight to call their wife the moment you walk into the room.  At least, I can give them credit for thinking ahead. 
  5. Men have limited attention span so try to keep your explanation to 1-2 key points (Cush, are you still with me?); talk about the point that matters most to them first: will the drug decrease libido, or will it cause hair loss? Let me give you an example. My male patients always take their folic acid; it has not always been this way until I found the trick.  Go over methotrexate side effects, including hair loss, then give them the zinger—folic acid can decrease methotrexate toxicity including hair loss. 

According to the CDC website (www.cdc.gov),    the average male life expectancy is 76.3 years and for females 81.1 years.   Compared to their male counterparts, women have greater stress/depression/anxiety, they suffer more chronic illnesses, are paid less, taxed more (#axthepinktax) and more likely victims of violence, yet they outlive men. Why? Most likely because women take care of themselves and are better patients.

While the above discussion suggests why women are better patients, the ultimate evidence is in your blogs, Jack—you wrote 3 times more blogs about female patients than about male patients. In fact, there are only 3 blogs that mentioned men of which one is about you after your knee replacement and the other is about a drug rep passed out in a hotel room (who is not even your patient). Without women patients, your blog contents would be limited (and we would be out of practice).

 

 

Disclosures: 
The author has no conflicts of interest to disclose related to this subject
jjcush

Kathryn Dao, MD, FACP, FACR, is the Associate Director of Clinical Rheumatology at Baylor Research Institute in Dallas. She is in clinical practice at the Arthritis Care and Research Center in Dallas, TX and is actively involved in patient care, medical education, and clinical research.  Her interests include Rheumatoid Arthritis, Systemic Lupus Erythematosus, Gout, Infections with Biologics, Osteoporosis, and Drug Safety. She has served as the co-editor for the American College of Rheumatology “Drug Safety Quarterly” 2010-2013.   

 
Dr. Cush is the Director of Clinical Rheumatology at the Baylor Research Institute and a Professor of Medicine and Rheumatology at Baylor University Medical Center in Dallas, TX. He is the Executive Editor of RheumNow.com and Co-Editor of the online textbook RheumaKnowledgy.com. Dr. Cush's research and interests include novel drug development, rheumatoid arthritis, spondyloarthritis, drug safety, pregnancy and Still's disease/autoinflammatory syndromes. He has published over 140 articles and 2 books in rheumatology.
He can be followed on twitter: @RheumNow.

Rheumatologists' Comments

Thank you both. After a long clinical career in Rheumatology and numerous anectodal, but highly informed experiences, I can attest that male physicians are far worse patients than female physicians. This "not so great debate" will undoubtedly generate much more heat than light. Congratulations.
I'm laughing- out of fond recognition of this dyad- or multiyad
You are BOTH correct!
That was worth the read! Made me laugh after a long day. I cant argue with either one...
The better patient is one with abnormal labs and xrays that perfectly correspond to their complaints and whose diagnosis has been missed by all preceding doctors.
Concuerdo que la paciente es más compleja ya que tiene diversos factores de la vida diaria que afectan su enfermedad. El hombre es más calmo y siempre tiene una enfermedad más grave. Pero en mí experiencia cumple su tratamiento y escucha lo que el médico le dice con mucha atención. No Googlea tanto. También debemos pensar.....y nosotros? No sesgamos al paciente ante ciertas palabras y /o comportamientos del paciente??? Me encanta leer Rheumnow!!!!