A study in the most recent issue of the CMAJ concludes that women undergo less orthopaedic procedures in Canada because of physician gender bias. The study was an interesting one, using patient actors covertly visiting orthopods and family physicians. The ethics of the whole affair is brushed off by an accompanying article titled In Praise of Undercover Research. Well then, I guess there can't be any controversy there, right? But before we get to the study ethics, let's look at the study itself.
Two patients, one male and one female, with known osteoarthritis of the knee were trained to act out a very detailed scenario of a patient the authors feel would be a good candidate for arthroplasty. A second pair with severe OA were given a similar scenario. The patients in each pair were equivalent according to the exam of two orthopedic surgeons involved with the study. The patients were also provided an X-ray of moderate OA and were then sent off to visit family MDs and orthopods. The following is a summary of the scenario.Download 16FFB1.gif
Of note is the last comment. If no surgery was recommended by the physician, the issue was to be pressed by asking if the time was right for surgery.
The actors/patients visited 38 family MDs and 33 orthopods over a two year period. First of all, the patients with severe OA were usually given the surgery recommendation, male and female, and this part of the study was dropped, with no further discussion in the results or discussion section.
Of the moderate OA patients there was a marked gender discrepancy. 90% of the surgeons recommended arthroplasty to at least one patient, while family MDs did so in 60% of cases. The male patient was twice as likely as the female to get a recommendation for surgery.
The authors conclude that there is a major gender discrepancy and only three possible explanations.
1) conscious sex discrimination
2) unconscious discrimination
3) the presentation styles of the actors may not have been identical
There are, however, some big problems with this study;
The authors consider that the best care of these patients was surgery, based on the fact that 90% of surgeons recommended surgery for at least one of these patients. That may be true, and I don't think it is, but even if it was the case, is it appropriate for a family MD to recommend major orthopaedic surgery to a patient on their very first visit?
Was it really time for surgery? Six months of pain, none at rest. Could we possibly try some other meds, a second injection, try injecting a problematic bursa or ligament, perhaps viscosupplemantation? Maybe that's why the family MDs were not in such a rush. Orthopods, of course, are less likely to go this route, thinking that the patient is referred specifically because these things didn't work.
Family MDs might also be a little reluctant because of past experience. While the surgery is usually great, there are failures, and it is the family MD that deals with the grief of a failed arthroplasty more than the surgeon. A few bad cases and a family MD might slow down the referrals, but a surgeon is not going to stop operating.
As for the patient actors, there are many possible reasons other than discrimination to explain the difference. While all patients in Canada do have access to surgery, the surgeons OR time is the limiting factor. They all have long waiting lists and therefore can be very selective. It is quite conceivable that the female patient, despite her training, did not come across as being ready. "Is it time for a new knee?", can be said as a question or as a statement. Was the female patient unpleasant, hideous, foul smelling, alcohol on her breath? None would be a good reason to alter treatment, but could be a different bias than simple sex discrimination.
The study lasted two years. Is it possible that the male's knee worsened more than the female. The study orthopods considered the two knees equivalent and surgery worthy, but is that a good enough standard.
The patients with severe disease did not experience sex discrimination. The authors did not feel this warranted any consideration except for a mention in an appendix that "It is somewhat reassuring to know that there is some threshold at which total knee arthroplasty is recommended to both male and female patients." This is unwarranted guesswork. It's quite possible that these patient-doctor interactions represented the true thought processes of the physicians and the other pair was the anomaly. Are the authors as biased as they claim the doctors were.
Don't get me wrong. Research does seem to show that women get less surgery for their ortho problems, but this study doesn't add much to the discussion.
