It might come as a surprise to some, but the model of American medical education in the twentieth century is based on the military model. The hierarchical command structure is militaristic in nature, with the physician on top of the command chain. The development of the culture of Medicine in the U.S. has been profoundly influenced because of this model.

Since the American military has traditionally been male-oriented and male-dominated, it follows that medical training built on this foundation tends show a bias that downplays the importance of women -- both as physicians and as patients.

The educational process begins at variable points for the specific individual. There are those students who have always known that they wanted to "be a doctor". For them, medical education began in elementary school. Typically, the process begins in earnest during the High School years, when thoughts of "what do I want to do with my life?" begin. There are others, like me, who made this decision during their college years, when the specter of finding a job versus furthering an education came to the forefront.

Regardless of the timing of the decision, the final common pathway is medical school. In the United States, there are about 127 medical schools. Arrival at the medical school of your choice is the result of extraordinary long hours of study and perseverance and competition.

Like a military bootcamp, the process of indoctrination takes place from the very first day at medical school. A lot of time is spent talking about how outstanding we all are, and how we are the "elite" who made it in. After all of the self-congratulatory behavior, the realities set in. We will take 8 to 12 classes each semester for the first year, and we must pass them all.

With what seems to be an impossible task before us, the focus is not so much on learning and understanding, but upon the rote memorization of "facts." I coined the term "factmaster" for myself during the training process. Memorizing large amounts of unrelated information was essential in order to pass the examinations later, and questioning the nature of the information would have used up valuable mental resources which then would not be available for memorization.

So it is in this environment that biases in the content of medical knowledge and education go overlooked and thus become accepted as another "fact."

In med school, "human physiology" was about male physiology. The workings of the organ systems in the body: brain, heart, kidneys, lungs, blood, marrow, and all the equations involved in explaining their actions and interactions. Only after the basic male components of physiology were completely explained and understood did we delve into what was considered the "variant" of the "normal", i.e., female physiology.

Similar subtle biases were experienced in other classes: psychology and psychiatry, pharmacology, neurosciences. This idea of female physiology as a deviation from the "norm" carried over into the clinical years, when variances from the basic male physiology were considered to be complications and often regarded as treks into the unknown.

This situation became obvious when, during the third year of medical school, a rotation into obstetrics and gynecology was required. The gynecologist knew about all these "deviations" from normal physiology. Women of childbearing years were considered automatically problematic. They were assumed to be pregnant unless proven otherwise. Because of this assumption, many treatment protocols are withheld from them, or not even considered.

Pregnancy itself represented, in the context of this philosophy, a huge departure from normal human physiology. All the rules regarding fuctioning of the heart, bone marrow, immune system and nervous system changed. Ignorance and the fear of doing the wrong things for a pregnant woman were common. Doctors, faced with a departure from the familiar, often gave less attention to these "deviant" physical specimens.

The reasons for this state of affairs are complex, but there are a couple of identifiable elements which may help to explain the situation.

Medical research has focused on male subjects because historically it was considered "indelicate" to experiment on women. Since many of the experiments done on living humans involved some degree of risk, it had always been felt that women should not be involved in such risk. This is not unlike the attitude of many towards women in the military.

Another major consideration is that women of childbearing years are assumed to be pregnant. The risks of complicating a pregnancy because of medical experimentation were considered unacceptable. Prior to the 1960s this was an ethical decision, and afterward, a liability-based decision as well.

The result is that physicians come out of med school harboring an attitude towards female patients that is hardly conducive to providing the best health care to women. Even female physicians are not immune to this insidious indoctrination.

Women often complain that their doctors treat them as "inferiors" and/or seem to brush off their concerns about their conditions. How could it be any other way, when physicians' training has emphasized repeatedly that there is something inherently "wrong" with the female body, that regardless of how healthy it is, it's still somehow "abnormal?"

Before we can expect doctors to change their ways of interacting with the women whose illnesses they treat, we have to change the way they're educated, so that they don't equate the very state of being female with abnormality.

THOMAS W. SHINDER, M.D. is a neurologist-turned-computer systems engineer who practiced medicine in Texas, Oregon and Arkansas before moving to his present home in the Dallas-Ft. Worth TX metropolitan area.

Copyright^© Thomas W. Shinder, M.D., 1997 All Rights Reserved