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Addressing patient gender bias toward trainees in the field of andrology

      At the time one of us (M.S.) entered urology, it was a male-dominated field. Throughout his training, he worked with only one female resident, which was not unusual at the time. While the subject of urology encompasses disorders of both the male and female genitourinary systems, most patients, at that time, were male. A literature search for articles on female urology before 1980 drives home this point. The field of andrology was perhaps an even more extreme example. The field was almost exclusively male, and the few women in the field were medical andrologists, not urologists. Bringing residents and fellows in to see and examine patients was rarely an issue. The male patients expected a male physician, and both the doctors and trainees they saw were men. When requests were made to exclude a trainee from a visit, it was attributed to wanting to minimize the number of people in the room and not due to the trainee's gender.
      The field of andrology encompasses male reproductive medicine and surgery, and it is unique, even within the world of urology. Urology in general deals with sensitive subjects and can include sensitive examinations such as prostate exams. Andrology takes this to another level as it focuses on reproduction and sex. Issues such as sexual and erectile dysfunction, ejaculation problems, and other reproductive issues are topics that patients and even many physicians are not comfortable speaking about. This is a growing field, and for those that enter this field, comfort with discussions of very personal topics is critical. Patients need to feel relaxed and safe enough to honestly discuss topics they have probably never discussed with anyone before, including friends and partners. The physician must be sensitive to the patient's view and be able to engage the patient, to determine what exactly the problems are, and to assist patients in accepting and understanding the issues as well as in pursuing treatment recommendations. While all fields of medicine deal with these general issues of trust, in reproductive medicine, tensions tend to run higher. Issues of culture, belief systems, identity, and gender combine with innate sensitivity and privacy concerns.
      The medical field gender ratios have reversed, with women representing more than 50% of medical school classes (
      ). The field of urology is also changing and evolving, with approximately 30% of entering urology residents being women (
      ). In our programs, over 50% of the residents are female. Although in years past, women in urology seeking fellowship training were expected to focus on female urology, ever increasing numbers of women urologists are now pursing fellowships in all urologic subspecialties including andrology. While institutional attention is being turned to the issue of gender bias, this often is within the context of interactions with faculty and staff. The issue of patient interactions and gender bias, especially in the field of andrology, is often not addressed. For those in academic institutions with female medical students, residents, and fellows, the issue of patient expectation bias is often not openly addressed.
      The field of gynecology provides an interesting juxtaposition to that of urology. While currently most gynecology trainees are female, in the not so distant past they were primarily male. The medical profession expected female patients to accept male physicians—and male trainees. Today with the reversal in gender ratios in trainees, female trainees are asked by patients to leave during the exam and in some instances not to be present during the entire visit.
      How do we as educators deal with this issue? It is not something that we commonly discuss in faculty forums, but it raises a variety of ethical and practical issues that warrant discussion. Is it fair to the trainee to be excluded from certain learning opportunities and experiences strictly because of gender? Do we impose our view of equity on the patient? We as clinicians understand the anxiety and apprehension that male patients may bring to the office. We know they often delay seeking medical care due to embarrassment. They often view sexual dysfunction as something to be embarrassed about and have never spoken to anyone else about this issue. Additionally, the physical exams that may be performed during these encounters may involve measuring the size of their genital organs as well as other assessments not usually performed during their prior interactions with their primary care providers. The patients may choose a particular clinician for specific reasons, but we should not confuse a patient's preference for a patient's needs. If the patient made an appointment with a male physician, is it fair that he be made to see a female one? His decision to choose that physician may be due to his own gender bias—which may be due to his own discomfort discussing his reproductive issues or his own implicit bias regarding the competency with which a female andrologist might be able to maneuver the delicate psychosocial context. How do we reconcile this with the trainee's expectations and sense of equity? To some extent, this leads to opposing needs—those of the trainee and those of the patient. We need to be cognizant of these and other issues and be ready to deal with them.
      For those clinicians routinely involved in reproductive training, there are a variety of approaches to address both needs—if the issues are thought out before they arise. While many of these are from local experience and therefore may represent our own population and biases, they often avoid uncomfortable interactions and unfulfilled expectations. It is not surprising that patients may have expectation bias; dealing with this before it arises will often avoid confrontations. Patients coming to teaching institutions may or may not expect trainees to be present. They may also be concerned that they will only see a trainee and not the doctor whom they expected. Having office staff inform the patients that they are in a teaching institution and that trainees are involved in their care is an important step. This can easily be discussed at a variety of times—at the time of scheduling the appointment, when they check in to the office, and/or when they are brought into the exam room. These all represent opportunities to reduce patient anxiety and improve the chances of avoiding misconceptions. This can be expressed as a benefit and not an apology.
      Proper instruction of the trainee is also important. Simple introductions by the trainee that explain the trainee's role to the patient often break the ice. Similarly, the trainees need to be comfortable with discussing these sensitive issues with patients. While they may have their own biases and views, they must learn that patients do also and that our job is to manage their medical problem. This often requires putting our own biases aside and not commenting to the patient about the patient's biases. This is not to say all patient behaviors need to be accepted. There are certainly times when specific patient behaviors should not be accepted and the patient should be informed of this. Knowing how and when to deal with this line is an important skill to teach. Responding to a patient wanting a female trainee to leave the exam room because he is uncomfortable is quite a different issue than male patients asking the trainees out for a date while they are being examined. Performing the physical exams jointly with the trainee often allays patient fears as compared with having the trainee perform a complete history and physical, reporting to the attending physician who then repeats the process. As trainees progress in their own comfort and skill set, they are better able to sense when to perform an independent exam and when to involve the attending. Despite adequate preparations, there are still instances when patients do not want a female in the exam room. This is the patient's prerogative, however, and with adequate forethought, these instances can become uncommon and therefore not impinge significantly on the trainee's education. Having a toolbox of approaches for different patients and different situations is valuable and limits instances of confrontation. Most experienced educators have accumulated wisdom and approaches that they use, but these are often not discussed and shared. This leaves younger faculty to reinvent the wheel. This discussion has focused on gender bias in the exam room; however, equally important to discuss openly are bias incidents expressing racial and ethnic discrimination and how individuals and institutions can respond in real time (
      • Warsame R.M.
      • Hayes S.N.
      Mayo Clinic's 5 step policy for responding to bias incidents.
      ).
      Interacting with trainees should not be viewed as a chore. Involving trainees is often very beneficial to patient care as they may spend more time interacting with patients and obtaining trust and a medical history that we, with full schedules, may not be able to obtain. They can provide a new outlook and opinion on a case that can be beneficial. As gender ratios in medicine continue to change, being aware and proactively dealing with these issues ensure educational opportunities for future students and avoid patient anxiety and stress. Patient care is our top priority, but with proper thought and planning, patient care and education can both be accomplished, often leading to increased benefit for all.

      References

      1. Women were majority of U.S medical school applicants in 2018. Association of American Medical Colleges, Washington, DC2019 (Available at:)
      2. Urology residency match results announced. American Urologic Association, Linthicum, MD2019 (Available at:)
        • Warsame R.M.
        • Hayes S.N.
        Mayo Clinic's 5 step policy for responding to bias incidents.
        AMA J Ethics. 2019; 21: E521-E529