'Grey's Anatomy' Finally Tackles Medicine's Gender Bias - Pacific Standard

'Grey's Anatomy' Finally Tackles Medicine's Gender Bias

With Miranda Bailey's heart attack, sexism in medicine gets much-deserved mainstream treatment.
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In her early 30s, Elisabeth Finch spent years seeking an explanation for her persistent knee pain, which four failed surgeries couldn't seem to alleviate. Her surgeon eventually "released" her as a patient; he prescribed antidepressants for the back pain that kept her up at night and said he didn't think there was anything more he could do for her. Finally, a different doctor diagnosed her with a rare bone cancer, which, by that point, had spread to her spine, requiring years of bi-weekly chemotherapy sessions and multiple surgeries.

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At the time, Finch hadn't considered that sexism was lurking behind her doctor's dismissive treatment. "He called me 'impatient' and 'emotional,'" she later recounted in a piece at Elle. "It never occurred to me that being 'female' was perhaps the most dangerous label of all." But once she dug into the research, she began to see her story not as a freak anomaly but as part of a pattern. She went back and confronted her first doctor about the diagnosis he had missed. "I expected fireworks and an epic speech in which I righted every wrong and brought him down to size, swooping out in a superhero cape and a flurry of self-righteousness," she wrote.

It didn't go down quite like that. Finch—a woman after my own heart, apparently—settled on sending the doctor a biting follow-up note. But while most of us are destined to stay up at night replaying those epic speeches we didn't make in our heads, Finch, who is a writer for Grey's Anatomy, put them in the mouth of none other than the reigning queen of epic speeches herself: Dr. Miranda Bailey.

In last week's episode, which was written by Finch, Grey Sloan Memorial Hospital's beloved chief of surgery realizes she's having a heart attack. Reluctant to be fussed over by her own colleagues, she goes to another emergency room for help. But when her EKG comes back normal, the doctors insist her heart is fine and begin a different line of questioning: "Any big stressors in your life?" In typical Bailey fashion, she promptly calls this out for what it is: "Do not go down that road with me: The road where a woman shows up in an ER with physical symptoms, and you decide that it must be that she's not able to handle all her feelings. No, this is not about anxiety. My secret heart doesn't need fixing. My actual heart needs fixing."

Grey's Anatomy is the most progressive show on television, and when it has a message to get across, it's usually not subtle about it. Just the week before, a storyline about a young black boy shot by cops (as he was climbing in the window of his own house) provided occasion for impassioned and on-point speeches about police violence and implicit racial bias. And as a devoted fan of the show for all 14 seasons, I have been awaiting this particular episode for years: the one that tackles the insidious gender bias within the medical system.

As I've reported for Pacific Standard before, Bailey's experience is not rare. Women with heart disease—which takes more lives each year than all forms of cancer combined—tend to be treated less aggressively than men overall. Younger women are particularly prone to being dismissed. According to a 2000 study, women under 55 were seven times more likely than the average patient to be discharged from the emergency room in the middle of having a heart attack. Black women are treated less aggressively compared to both black men and white women—despite the fact that, as Bailey points out to her doctor, black patients are at significantly higher risk of heart disease than their white counterparts. And women are often stereotyped in just the manner Bailey was: as overly anxious. In a 2015 study, 44 percent of women with heart disease said they felt health-care providers trivialized their complaints and attributed them to psychological causes. As one woman in the study said, "Doctors think that men have heart attacks and women have stress."

Bailey had indeed been experiencing a lot of stress lately—even more than usual in the trauma-per-minute universe of Grey's Anatomy. That fact should have been all the more reason for doctors to be concerned about her cardiovascular health. Stress is, in fact, a risk factor for a heart attack—and likely would have been perceived as such if she were a man. In a 2008 study, physicians evaluated two similar hypothetical patients—one male and one female—complaining of textbook heart attack symptoms. When the doctors were told the patient had recently experienced a stressful life event and appeared to be anxious, only 15 percent diagnosed heart disease in the woman, compared to 56 percent for the man. The presence of stress, the researchers explained, seemed to spark a "meaning shift" in which women's physical symptoms were reinterpreted as psychological, while "the men's symptoms were perceived as organic whether or not stressors were present."

The episode also addresses the second strike working against Bailey as she tries to get the doctors to believe her: She has a history of mental illness. When the subject of her medication for obsessive compulsive disorder comes up, she again preemptively tries to keep her doctor from letting that cloud his clinical judgment: "Yes, I have obsessive compulsive disorder. I'm not ashamed of that, but it's not my story. It's just one piece. And if you continue to look at just that one piece—if you check the mental illness box and refuse to look at anything else—then I'm not going to live long enough to finish the rest of my story." She is warning him against making what experts in diagnostic errors call the "psych out error," in which patients with psychiatric conditions find their physical symptoms overlooked, minimized, or misdiagnosed as psychological. It's a mistake that women, who are about twice as likely to have common mental-health diagnoses like anxiety and depression, are especially vulnerable to.

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Bailey is battling against a problem that Dr. Bernadine Healy, the first woman director of the National Institutes of Health, diagnosed as "the Yentl syndrome" back in 1991—and which women's heart experts say is alive and well today. Decades of foundational research on heart disease conducted almost exclusively on men had produced a "male model" of the disease and a "myth that coronary artery disease is a uniquely male affliction," Healy explained. The result was that women with heart disease were under-diagnosed and under-treated until they proved that they were as sick as their male counterparts. "Once a woman showed that she was just like a man, by having severe coronary artery disease or a myocardial infarction, then she was treated as a man would be."

The Yentl syndrome is a major obstacle for many women with heart disease because, very often, they do not, in fact, present "just like a man." Apparently Bailey's doctor didn't get the memo that, just because she isn't clutching her chest and left arm and dropping to the floor in the classic "Hollywood heart attack," that doesn't mean she's not having one. Over the last couple decades, research has revealed that women are more likely to experience "atypical" heart attack symptoms, such as a feeling of indigestion, jaw pain, upper back pain, nausea, and fatigue. (There's even some research to suggest that symptoms may vary according to the intersection of race and gender.) Furthermore, women's heart experts have identified a whole new form of "female-pattern" heart disease that's undetectable by the standard cardiac tests and continues to frequently go undiagnosed. And Bailey's doctor is certainly not the only one to miss the memo: A poll commissioned by the Women's Heart Alliance a few years ago found that only about half of physicians agreed that there were differences between men's and women's hearts.

Yet even women experiencing "typical" heart attack symptoms are too often misdiagnosed. Carolyn Thomas, author of the blog Heart Sisters and the book A Woman's Guide to Living With Heart Disease, is one of them. And as a patient advocate, she has met many other women with similar tales. "I often say if that emergency room doctor had only googled my symptoms at the time, there's only one diagnosis that would have popped up, really," she told me when I interviewed her for my forthcoming book on gender bias in medicine. "Had I been a man who had presented with central chest pain, nausea, sweating, and pain down my left arm, there is no doubt I would have been admitted for observation." Instead, she was sent home, assured it was probably just acid reflux—and most definitely not her heart—and, two weeks later, had another heart attack that nearly killed her.

And it's not just heart disease either. There's evidence that women patients face a Yentl syndrome more broadly: Thanks to a persistent stereotype that women are overanxious hypochondriacs, there is an initial tendency on the part of health-care providers to underestimate their symptoms until objective tests show that they are as sick as male patients. This results in gender disparities across a variety of contexts—from longer wait times for pain medication in the emergency room to longer diagnostic delays for brain tumors, rare diseases, strokes, and cancers.

It's this dynamic that Bailey is having none of from the get-go. "I am having a heart attack," she declares. "And I'm not going anywhere until you do a full cardiac work-up and prove it." It's a striking line since it explicitly reverses the operating assumption of typical doctors, particularly for women patients: that the burden of proof falls on the patient; that the patient is not truly sick until the doctor determines she is.

Of course, Bailey has far greater freedom to advocate for herself than most women—a reality that Chandra Wilson, the actor who plays the character, is all too aware of. She is a caregiver and advocate for her daughter who suffers from cyclic vomiting syndrome, a rare chronic condition that went undiagnosed for 10 months. In an interview with Wilson about the episode at Shondaland, Finch writes that the two have swapped medical "war stories" and bonded over their shared "knowledge of how hard it can often be, as women in particular, to be seen and heard when managing chronic illness." According to Wilson, it requires walking a "fine line" between pushing for the care you need and antagonizing the doctors with your knowledge. As Finch notes, "It's like a constant dance of, 'I want to advocate for myself, but I also don't want to come off as too insistent.'"

Bailey, though, has the authority to insist—even if her insistence doesn't actually get her that far. And, as importantly, she has the medical expertise to be confident in her assessment that she's having a heart attack, even as all the doctors around her question it. And this is perhaps where her experience most diverges from that of the average patient. Bailey never once doubts herself: not when she demands a second EKG and it comes back normal. Not when she demands to see the chief of cardiology, and he refuses to do a stress test. Not when she demands a second opinion, and they send in a psychiatrist, who inquires about her "home life" instead.

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In reality, if you aren't a medical professional, it is very difficult to trust yourself—and the truth of what your body is telling you—when an expert in a white coat is wielding his M.D. from Yale University and saying there is nothing wrong. As Katie Ernst, who runs the blog Miss•Treated (which features reader-submitted stories of medical sexism) and whose lupus was brushed off as depression for years, told me, "You start thinking that maybe you are a little bit crazy and you start wondering if maybe you are making up your symptoms." No matter how empowered a self-advocate you'd like to imagine you'd be in that situation, it's a challenge for anyone not to internalize a doctor's gaslighting, and it is hard especially for women in a culture that is very good at teaching us to second-guess ourselves.

Which is why, as satisfying as it was to watch Bailey dole out one of her signature take-no-bullshit speeches to everyone standing between her and a full cardiac work-up, I think the most important line of the episode was delivered by Dr. Maggie Pierce. As she repairs Bailey's heart, Grey Sloan's cardio chief—who, as a black woman, has (like Bailey herself) had to be twice as good to get to where she is—berates the white male doctor whose arrogance has resulted in the complication she's now working to fix. He cuts her off: "Dr. Pierce, I understand you're upset." It's a comment that echoes what Finch's real-life doctor said when she questioned him about whether there was anything that should have tipped him off to her cancer years ago: "You seem angry...."

Yes, we are. Because you shouldn't need to be Miranda Bailey to get a doctor to listen to you. "I'm not upset; I'm furious," Pierce replies, spitting the word at him from that deep well of justified rage that's often easier to access on behalf of our sisters than ourselves. "And I am grateful. I am grateful that Dr. Bailey fought for herself like she does for her patients every day, and I am furious that she even had to."

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