INTRODUCTION: THE PROBLEM WITH MEDICINE AS EMPOWERMENT
IN PASO ROBLES, CALIFORNIA, a woman returns to the clinic where she had an IUD inserted to have it removed, because, in her words, “I went from a happy-go-lucky 31-year-old to a depressed walking zombie in just 3 weeks.” The clinician refuses—tells her she doesn’t think it’s a good idea, tells her to wait six months, says what happens when you have an abortion? After making her case and being denied multiple times, the patient, shaking with anger, turns the request into a demand. The clinician rolls her eyes, takes the device out, and wordlessly leaves the exam room.
In Somers Point, New Jersey, a woman having her second baby is nine (out of ten) centimeters dilated, on hands and knees with her midwife, feeling the urge to push, when the obstetrician on call enters the room, asks about the woman’s previous delivery (vaginal), and tells her she’ll need a C-section this time. When the woman asks questions, the doctor threatens to call “legal people” if she doesn’t sign a consent form for surgery.
In Minneapolis, a 46-year-old woman at a renowned medical center has a robotic, “minimally invasive” hysterectomy. Two days later she tells the nurses of concerning symptoms: pain, elevated heart rate, increased respiration. Doctors note “anxiety” in her chart, administer Ativan through her IV without telling her, and discharge her with a prescription for the antianxiety medication. Two days later she wakes up in pain so unbearable she calls for an ambulance. It turns out her intestine had been damaged during the hysterectomy—she emerges from emergency surgery with a colostomy bag.1
You may already be familiar with a version of this story: Woman needs medical care. Woman is ignored. Woman has to fight.
The patient-doctor relationship is among the most sacred in the secular world. We surrender our modesty and trust our physicians—especially our OB/GYNs—with our most intimate needs and vulnerabilities. In return, at a minimum, we expect science, expertise, and respect. Elizabeth Blackwell, the first U.S. woman to get a medical degree, noted the gendered power imbalance inherent in the relationship and advocated for women’s equal representation in the profession. “It is not only by what women will do themselves in medicine, but also by the influence which they will exert on the profession, that they will lead it to supply the needs of women as it can not otherwise,” she lectured in 1859.2
Today, half of all medical students and some 60 percent of OB/GYNs are female, yet our dignity in the medical realm is no more secure.3 Neither is our health. A 2013 Institute of Medicine report found that even as women’s life expectancy has risen overall, U.S. women are “dying at younger ages” than our international peers, a trend that has been worsening for three decades.4 And the quality of those years we are living is worse than men’s, and worse than the previous generation’s.5 A 2013 study of some 2,000 mother-daughter pairs in the United States found that the daughters “entered adulthood at greater risk for the development of chronic illness than their mothers.”6 In 42 percent of U.S. counties, women’s life expectancy is decreasing.7
Shocked? I was too. Hadn’t we come a long way, baby, from the dark days when cervical cancer was the number one cause of cancer death in women, the days when breast cancer needed more “awareness”? Hadn’t we conquered perpetual pregnancies? Aren’t we all eating more fresh vegetables? And don’t women have more power now, in medicine as well as in society at large?
To try to explain it, one can parse the generational and international differences: We live in a more toxic environmental “soup” now than in our parents’ and grandparents’ day, and the lack of guaranteed health care is a unique driver in the industrialized world. Another explanation, to be blunt, is racism. Black women are more likely to die of heart disease, breast cancer, and pregnancy, and when researchers drill down to determine why, the salient factor is the stress caused by the daily wear and tear of being a woman of color in twenty-first-century America. Health disparities hold true for men of color as well.
But why is our health slipping when women in the United States visit more doctors, have more surgeries, and fill more prescriptions than men?8 Bias is a problem—women having heart attacks and strokes are more likely to be misdiagnosed by ER docs and sent home. “Women,” concluded a 2017 article in Glamour, “are more likely to be misdiagnosed in pretty much any medical situation.”9 Hormones are a problem—not our own, necessarily, but the endocrine-disrupting chemicals that have infused everything from lotion to tap water. Research funding is also a problem—for example, autoimmune disorders affect a stupefying 10 to 20 percent of the population (depending on how many diseases you put under the umbrella) and some 75 percent of sufferers are women, yet these diseases claim a fraction of investigative efforts.
Another problem has emerged in recent years: too much treatment.
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In November 2009, the U.S. Preventive Services Task Force (USPSTF), an independent group of physicians and researchers that makes recommendations on disease screening, ignited a firestorm when it recommended that women get fewer mammograms. The announcement came in the midst of a 15-year-long breast cancer awareness campaign. Pink ribbons were everywhere and the “early detection saves lives” mantra had been burned into the public consciousness. Despite this, the USPSTF announced that, based on epidemiological evidence, women would be better off if they held off screening until age 50 (rather than 40) and screened every two years rather than annually.
For many, it just didn’t (and still doesn’t) make sense: why would it be better for women to screen later and less often?
Sometimes, you wind up sitting next to just the right person at lunch. I was at a health conference around the time of the USPSTF’s pink grenade, and that person was Ned Calonge, then the task force’s director. Calonge gave me the cancer-screening spiel that he was frequently giving to audiences of clinicians at the time: there are five outcomes to a screening test, and four of them are not going to help you live longer or better. One, the test could be wrong—you don’t actually have cancer—but you get unnecessary biopsies, surgery, or treatment, potentially causing harm. Two, the test could be right in detecting some abnormality, but what it detects is never going to progress into invasive cancer. Three, the test could also be wrong in the false-negative sense—you really do have an invasive cancer, but the test says you don’t, so you ignore your symptoms. Four, if the test finds nothing and indeed you have nothing wrong, you are no better off than when you began. Only in the case that the test finds a bad cancer before you had noticeable symptoms are you potentially gleaning a benefit. Calonge’s point? Think before you test.
In the case of mammograms, Calonge explained, the problem was that for every handful of lives saved, thousands of women were getting unnecessary, potentially harmful treatment. Years of annual screening, he said, had not delivered a net benefit.
In the connected realms of overtesting, overdiagnosis, and overtreatment, women are more vulnerable than men. We’re recommended bone density scans and then prescribed drugs to treat “osteopenia,” though the machines, diagnosis, and treatments were all manufactured by the pharmaceutical industry—and it turns out these drugs often lead to bone loss and fracture.10 Routine thyroid cancer screening came into vogue in the 2000s, though now we know that some 80 percent of the resulting surgeries, in women specifically, were done unnecessarily.11 Men and women are equally obese, yet women are more often recommended bariatric surgery. We’re more likely to be prescribed antidepressants and antipsychotics and recommended electroconvulsive therapy.12 We’re also more likely to be prescribed opioids, and 40 percent more likely to become dependent on them.13 We are prescribed more drugs and are recommended more surgery in general.
In particular, we endure a lot of surgery on our sex organs. For the past several years, roughly one-third of U.S. women giving birth have done so via cesarean section—major surgery that carries serious short-term and long-term risks to baby and mother, particularly for future pregnancies. While some of these operations are necessary, many are not. There is a statistical threshold at which the harms outweigh the benefits, and public health authorities agree that at our rate of 32 percent cesareans, we’re well above that threshold. This trend raises questions not only of appropriateness but of consent. There are hospitals in places like northern New Jersey and Miami, Florida, where there are more C-sections than vaginal births, and hundreds of hospitals have de facto bans against vaginal birth if women have had a previous cesarean or are carrying a baby in the breech position, leaving them no choice but surgery.
The cesarean rate is now a public health crisis—a likely contributor to the rising number of maternal deaths. And most maternity care is still largely an outdated, one-size-fits-all assembly line: clinicians frequently induce and speed up contractions, immobilize women on their backs, restrict food and water, and tell them when and how to push—if they aren’t pushed into the operating room first. “If overtreatment is defined as instances in which an individual may have fared as well or better with less or perhaps no intervention, then modern obstetric care has landed in a deep quagmire,” maternal health leaders warned in a 2014 report.14
Copyright © 2019 by Jennifer Block.