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Saturday, July 4, 2020

Sex Matters

Emergency physician shows everyday readers why ‘Sex Matters’ in health care
Brown University

Sex Matters, Book CoverDr. Alyson McGregor was just finishing her residency at Brown’s Warren Alpert Medical School when a major medical finding broke: The classic symptoms associated with heart attacks, shooting pain down the left arm and crushing pressure on the chest, were in fact typical only of men. 

In contrast, women suffering heart attacks were likely to report subtle symptoms, like fatigue, upset stomach and shortness of breath. 

The findings helped explain why women were more likely than men to die from heart attacks and suffer undiagnosed cardiovascular disease.

“We physicians were taught that men’s symptoms were the standard for both men and women,” said McGregor, now a faculty member in the school’s Department of Emergency Medicine and physician at Rhode Island Hospital. “It turned out that didn’t fit women’s experiences.”

The findings spurred McGregor to consider other ways that inattention to biological sex difference might be impacting the health care women receive. “I thought, ‘If women are different in this way, why? And how are they different from men in other ways?’”

McGregor cofounded the Division of Sex and Gender in Emergency Medicine at Brown to answer these questions. Since its inception in 2014, the division has helped to generate more than 100 peer-reviewed publications on a vast range of medical conditions — from infection to cancer to stroke — and trained numerous medical residents through elective rotations and a two-year fellowship designed to develop new leaders in the field. 

Most recently, McGregor turned her sights to educating the general public about the difference that sex makes in health care. Her new book, “Sex Matters: How Male-Centric Medicine Endangers Women’s Health and What We Can Do about It,” gives an accessible account of health care disparities that continue to affect women, with an eye toward empowering women to fight medical biases when they encounter them.


“I try to offer specific instructions for women on how to get the most out of their care and how to advocate for themselves,” McGregor said. 

Following the book’s debut, McGregor discussed the root causes for the gap between men’s and women’s care and the ways that “Sex Matters” extends her work as an educator and physician.

Q: Why has Western medical research so persistently focused on men — to the point where men’s symptoms and outcomes are assumed to be typical for women, too? 

Before the National Research Act was passed in 1974, there were a few medication trials where women became pregnant and then had fetal malformations or gave birth to babies with severe birth defects. 

After the act established institutional review boards to evaluate the safety of clinical trials, the medical community decided that women of childbearing age should probably just be eliminated from these trials to protect them. And researchers thought this was a pretty good idea because accounting for women’s menstrual cycles — which have constantly fluctuating hormone levels — increases the cost of doing research. 

So there was this sort of relief among researchers as they thought, “Well, we'll just study men, and take those outcomes and apply them to men and women. You know, it should be close enough.” 

That's been the mantra — even as we've really started to discover that sex affects medical conditions of high public health significance — because the paradigm has been to use men. And it's hard to change that.

Q: Have there been policy changes in recent years that have challenged this paradigm? 

In 1993, the National Institutes of Health (NIH) began requiring that sex as a biological variable be accounted for in funding applications for clinical trials. 

They realized that the difference in sex chromosomes between men and women actually impact health, and that we should take that into consideration by not only enrolling women into clinical trials, but then — instead of just pooling the data — analyzing the data separately to look for sex differences. 

But we can't just have women included at the end of the research process. It wasn’t until 2016 that the NIH announced that sex differences need to be studied down the whole line — beginning with including female animals in preclinical studies — because we're talking about very specific cellular immune hormone related differences.

Q: What about race? How does it impact health care disparities between men and women?

Race has tremendous impact on health. For women, it compounds the bias that is already there. If we look at the differences between outcomes after a heart attack between men and women, women have worse outcomes because our knowledge base has been built on the male model for so long that we're not recognizing diseases or adequately understanding the side effects of medications, or even if they're effective. 

Then if you look at the difference in outcomes of heart attack among women, women of color have worse outcomes than white women. 

So not only do women of color suffer worse outcomes because they are women, they also suffer worse outcomes because of society's lack of considering race as part of their health. The medical community has really done research on white, healthy men as our standard. 

Q: In what ways has COVID-19 impacted your work on sex differences in medicine?

The unfortunate fact that men have a higher mortality rate when infected with COVID-19 has actually shown that studying sex differences is something that is not just about improving women's health. 

We’ve had to ask, does this disparity relate to a sex difference in the immune system? Does it have to do with estrogen or testosterone? Does it have to do with gender, cultural or behavioral differences between men and women? 

When you conduct research that separates out and compares data from men and women, it's actually about a better and higher quality of research for everyone. Both men and women will have benefits when you look for these differences. 

Q: How did you come to found Division of Sex and Gender in Emergency Medicine at Brown, and what are its goals?

The division began in 2014 when my colleague, Dr. Esther Choo, and I started to realize that women were biologically different from men, and that this wasn't necessarily accounted for in medical research or practice. 

The best way to really get the attention of your colleagues in the scientific field is with data, and so we said, “We need to start researching this. Let's create a research focus within our Department of Emergency Medicine, where we ask, ‘What important differences between men and women do we see in the emergency department?’” 

Because this is a teaching institution, we're also teaching the medical students and residents what we're learning. I’ve started to develop educational programs: elective programs for the medical students and residents, and then I created a two-year fellowship program to train new leaders in the field.

Q: Are there qualities about Brown that make it a particularly good home for this division?

Brown University is a particularly great place to discover your own niche. Many institutions, when you say that you want to do research, they say: “OK, well there are missions within the department or the university, and so, you know, here's an existing project. Why don't you start to look into that?" 

But the leadership of my department was very supportive. I find that the longer I've been here, the more I've learned about how open Brown is to being state of the art. 

The University also allows students to discover new avenues of interest and research. It's because of that that I’ve learned so much from working with the medical students here. They get it. They are so ready for forward thinking that it's very enjoyable to work with them.

Q: What projects are underway in your division that are particularly exciting to you?

One of the things that I am most excited about is the two-year fellowship program I created in 2011 — it has been such a joy to watch these emergency medicine graduates go on to create research and education programs around the country. 

I'm also part of a group that established a recurring Sex and Gender Health Education Summit in 2015 where we educate health educators. As we create all this data on the differences between men and women, the next step is to make sure that this evidence is shared with leaders in health education — doctors, nurses, dentists, allied health care professionals, pharmacists — so that they can teach their students how sex differences impact health care. 

Because this work is really not about me going to the medical school and giving one lecture on sex and gender. It's about every lecture, everywhere. As health professionals, we should be just naturally talking about significant differences between men and women so that students don’t have this one-size-fits-all model when they go out to practice.

Q: What made you write “Sex Matters”? 

I have spent the past decade publishing in scientific literature and increasing the data and the evidence indicating how sex difference affects medicine and trying to get it into health education. 

And then I would go to an emergency department shift and still see these women patients who are still burdened by the health disparities that are ingrained in our medical system. And I realized we don't have time to waste. We have to do better and we have to do it soon. 

And so I thought I would write a book that my mother and my sister can read — one that all women can understand so that they can feel empowered to navigate the health care system to help change it from within. 

Women — when they feel empowered and when they have ownership of their health information and they know the right questions ask — they will also be part of this revolution that I'm hoping occurs to increase our knowledge of women's health.