My talk at FIX19 was called from Evidence-Based Medicine to Feminist-Based Medicine. Over the last few years Dara and others have opened my eyes to some of the other limitations to EBM. You can get copies of my slides at this LINK.
Evidence-based medicine was originally defined by Dr. David Sackett over 20 years ago. He defined EBM as: “The conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients.”
I would add the word SHARED to this definition. The modified version would be “The conscientious, explicit and judicious use of current best evidence in making SHARED decisions about the care of individual patients.”
There is a Venn diagram used to represents the EBM definition. Many people think that EBM is just about the scientific literature. This is not true. The evidence informs and guides our care but it should not dictate our care. EBM also needs your clinical judgement based on your experience. We also need to engage with patients and ask them about their preferences and values.
These three components make up EBM: The literature, our clinical judgement and the patient’s values. If you do that, you will be giving patients the best care, based on the best evidence and engaging in a shared decision making model, or so I thought.
My eyes have been opened to the inequities in medicine by Dara Kass and other. I cannot look away any longer or stay silent These are the inequities I see in EBM.
The Medical Literature:
- Who gets most of the grant money in medicine? Men
- Who rises to the top academic positions at universities? Men
- Who rises to the top academic positions in medicine? Men
- Who rises to the top academic positions in Emergency Medicine? Men
- Who is most likely the first author on a medical publication? Men
- Who is most likely the first author on a emergency medicine publication? Men
- Who is most likely to be the first author on a Pediatric Emergency Medicine (PEM) Paper? Men 62% of PEM are women but only 42% are lead authors in the four high impact pediatric journals.
- Who are often excluded from being subjects in medical research? Women
- Who historically has been the clinician in the room? Men
- Who is most likely to rises to top leadership positions within the hospital structure? Men. Only 3% of healthcare CEOs are women, 6% are Department Chairs, 9% are Division Chiefs, and 3% are serving as Chief Medical Officers. This is despite women comprising 80% of the healthcare workforce.
- Who gets paid more in medicine? Men ($20,000/year)
- Who gets paid more in academic medicine? Men ($17,000/year)
- Who gets paid more in academic Emergency medicine? Men ($12,000/year)
- Who is more likely to be introduced with their professional title at grand rounds? Men (96% men vs. 66% women)
- Who gets mistaken for a nurse while wearing a white lab coat, introducing themselves as the doctor and is wearing a big badge that says PHYSICIAN? Women
- Who traditionally was more likely to access health care? Women
- Who is typically responsible for most family health care needs? Women Mothers make approximately 80 percent of health care decisions for their children.
- Who has been systemically under-treated when it comes to painful conditions? Women They are 7% less likely to get any analgesia and 10% less likely to get an opioid.
- Who are provided less care for life threatening illnesses like STEMIs? Women They receive less treatment and have double the odds of dying.
Medical research, publication and knowledge translation has gone online. Here is a new Venn diagram to represent the move from EBM to FBM (Feminist-Based Medicine).
With these changes, we need to ensure that women are getting equal access to grant money, so they can ask the questions important to women and create the medical literature that informs our care. This will also lead to more women being first author on a medical publication. We need to include rather than exclude women as subjects in medical research and not just extrapolate from male subjects.
Women make up at least 50% of medical school graduates at many institutions. A system must be in place to support those for those women who want leadership roles in healthcare. Pay inequity must end. We also need to change societal expectations that the highly qualified, competent individual who has just take care of their emergency situation and introduced themselves as doctor and wearing a name badge that says physician and happens to be a women is THE doctor.
It is not just women that access health care. The emergency department is the one place in the house of medicine that the light is always one and will treat anyone at anytime for any condition. We need to ensure that everyone gets the care they need regardless of whether they are a man or woman.
Dichotomizing things into men and women may offend some people. I recognize that this is a false dichotomy. It is not just about men and women. Gender is more complex and is on a spectrum. FBM is just the starting point and we need to take it one step further to GBM (Gender-Based Medicine).
Here is just a graphic representation demonstrating the complexity of gender and sexuality. We need to make sure that the house of medicine in not just inclusive and tolerant but accepting and welcoming to everyone regardless of how they identify.
The progression, in my opinion, should be from EBM (nerdy and male dominated) to FBM (opening my eyes and recognizing the inequities) to GBM (acknowledging the spectrum of gender and sexuality) to ultimately Humanist- Based Medicine (HBM).
We are one race, the human race. In order to provide patients with the best care we need high-quality, clinically relevant research that is inclusive and representative of everyone; remove all inequities for those who generate research and provide care at the bedside; and finally, recognize everyone has value and should expect and deserve great care.
This post originally appeared on Dr. Milne’s website, The Skeptics Guide to Emergency Medicine.
Watch the FIX19 talk here!