“Mr X presents with central crushing chest pain”—Breaking the male norm in medical education

Marina Politis deconstructs the ways in which our knowledge of, and teaching about, health and illness predominantly focuses on men

Medical education might have you believe that as future doctors we will solely be treating men. For whether it is an anatomical model, textbook, or multiple choice question, our teaching resources are often centred on a male norm as the default—women, if they are mentioned at all, are included only as an afterthought.

A quick Google search on how to place the leads for an electrocardiogram reveals endless versions of the same chest, but none dare feature a breast. If I open any clinical examination textbook in the library, after flipping to the cardiology chapter, it too confronts me almost exclusively with male bodies.

These incidents are all examples of what is known as androcentrism, the consistent prioritisation of a male centred perspective, resulting from and perpetuated by patriarchal, misogynistic male worldviews. In medicine it is apparent in all the ways in which our knowledge of health and illness predominantly focuses on men. Throughout all strands of society, men have been viewed as representative of the human species, while women have been seen as deviations from this norm, and medicine is not exempt from this. The concept of “otherness” was conceptualised in The Second Sex by Simone de Beauvoir, who stated “he is the Absolute—she is the Other.” 

This “othering” of women manifests in the treatment of conditions like myocardial infarctions. The stereotypical heart attack that we see presented in the media is always of an older man grasping his chest as he dramatically falls to his knees. In medicine, presentations that deviate from the standardised “tight-belt-around-chest” central crushing chest pain are seen as atypical. While women experience this pain, it has been found that they are, however, more likely to present with referred pain or symptoms other than pain. These presentations of myocardial infarctions are called “atypical.” If they were to primarily affect men, rather than women, would this still be the case? I suspect not. Coronary heart disease kills more than twice as many women as breast cancer in the UK every year and is the number one cause of death for women across the world, so we can no longer allow ourselves to portray this as a “man’s disease”.

In a Venn diagram, the conditions where we are told “aetiology poorly understood” overlap noticeably with conditions that primarily affect women. Yet most medical schools fail to mention the systemic exclusion of women from research or medicine’s history of misogyny. Instead, our curriculum simply skirts around questions like the mechanism by which oestrogen interacts with headaches, or why we know so little about lichen sclerosus, a condition that is 10 times more common in women than in men

I suspect that often these omissions are because women, once their reproductive organs lose the potential for child bearing, simply are not a priority to medicine and its male gaze. The World Health Organization has remarked that women’s health can no longer be limited to a woman’s reproductive capacity.

Androcentrism in medicine is both a feminist issue and a patient safety issue. This form of gender bias can cost lives. The British Heart Foundation, for example, estimates that between 2002 and 2013, the deaths of 8243 women in England and Wales could have been prevented had they received the same standard of care for a heart attack as men. That equates to almost two preventable deaths a day.

Gender awareness 

Medical education has swept this issue under the carpet for too long; gender is a key determinant of health and it must be treated as such. As future doctors, if medical students are gender aware, they will be better prepared to care for their patients and to contribute to greater equity and equality in health.          

Resolving entrenched gender bias in medicine must begin with conversation and reflection, for only then can progress be made. In 1818, it was only because French doctor Laënnec found direct auscultation on female patients’ chests using his ear uncomfortable that the stethoscope was created. It is telling that this invention only came about because of a male doctor’s discomfort, and not in order to improve female patients’ experiences of care. Yet, nonetheless, this shows how, by acknowledging differences in and barriers to patient care, positive change can be made.

In all of these conversations, we must also mention intersectionality and how experiences of gender bias will intersect with other identities that individuals hold, including, but not limited to race, social class, sexuality, faith, and disability status. Medical education must go further than solely moving from a male norm to a male-female binary; instead, we need greater awareness of how gender encompasses more than just the two distinct male and female identities.  

Clearly, differences in gender and gender biases must be acknowledged and discussed throughout the medical curriculum, and not disregarded or viewed as topics exclusive to women’s health. After all, Mr X, the 70 kg, able bodied, straight, cisgender, white male is only one of the many patients we will see. This call to action is not novel; in fact, the mainstreaming of a gender perspective in medical schools was adopted as a policy by the United Nations Fourth World Conference on Women in 1995. More than 25 year later, it is high time that this is put into action. 

Marina Politis is a third year medical student at the University of Glasgow. Twitter @marinadpol

Competing interests: Marina is the deputy chair for welfare of the BMA Medical Student’s Committee and a member of Doctors for Choice and the Medical Women’s Federation.