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Sex Matters in Healthcare | Dr. Alyson McGregor

Dr. Alyson McGregor is a physician, researcher and writer. She is also the director for the Division of Sex and Gender in Emergency Medicine at Brown University. She has written over 70 peer-reviewed publications and is the lead editor for the textbook Sex and Gender in Acute Care Medicine. Her TEDx talk, “Why Medicine Often Has Dangerous Side Effects for Women” currently has over 1.6 million views and she has recently released a new book titled Sex Matters: How Male-Centric Medicine Endangers Women’s Health and What We Can Do About It.

Georgie Kovacs: tell us about your background.

Alyson McGregor: I was born and raised in Rhode Island. I always wanted to be a doctor. I don’t know why but it was something that was always inside me. I realized that it was a very challenging goal. I went through all the training, did medical school at Boston University and then a residency at Brown University in Emergency Medicine. I’ve stayed there as faculty ever since and I love it. It’s a very busy, level 1 trauma center and I get to see lots of patients with different conditions and it’s very fulfilling.

Georgie: tell us about how you got into having such a passion around women’s health and how that plays out in medical practices.

Alyson: I was always very in tune with women’s rights and the women’s health movements of the 60s and 70s. I always felt very grateful to the women then who fought so hard to fight for equality for women. I kept that as always something of an interest. When I finally finished all of the training and started to work as a physician, I stayed on at Brown University. I wanted to do clinical research. It thought, “here’s my chance to meld my interest in improving lives for women and medicine.” As I began to create project ideas and seek out advisors, everyone thought that my interest in “women’s health” meant reproductive health or obstetrics and gynecology. There was this assumption that that was equal to women’s health. I was in the emergency department. Women are there for many things other than their reproductive systems. Heart attacks, strokes, infections. I started to wonder why there was this assumption that women were distilled down to their reproductive organs. About that time, the cardiovascular literature started to declare that women can present differently when having a heart attack than men. It was perfect timing for me because I thought that was very interesting. I wondered: why was this the case? If that was the case, what about all of the other conditions I see when I’m on shift? That was the moment where I thought, “I’m going to explore this more.” I started to develop sex and gender as my clinical research focus.

Georgie: with the work that you’ve done at Brown, you’ve taken it to the next level. You had a very popular TEDx talk and then wrote an amazing book. With what you’ve seen in the field of medicine, what drove you to write this book and do all of this research?

Alyson: I spent the last decade or so researching and publishing in scientific literature and adding to the evidence that these differences are important. These can mean life or death for women. I’ve also worked very hard to bring that knowledge into education in the health profession. That’s where we really learn and teach our healthcare providers. I want them to appreciate how important these differences are and to think about them in a very natural way. It really needs to be included in medical education.

Then, I would show up for another clinical shift and see the health disparities that women face right in front of me every day. We just don’t have time to waste. I couldn’t wait for research to catch up and for medical education to catch up. I want women to be able to learn about this in a way that they can feel empowered to be their own advocates in the healthcare system.

Georgie: there’s a quote from your book that really brings this home: “this isn’t only a women’s perception of how they are treated by their doctors and providers. This is a scientifically validated reality in the world of medicine, because women are misdiagnosed, under-treated and underserved in part because providers don’t believe them when they say something is wrong.”

I appreciate that you’re a physician who did the research and wrote about this. This way, it doesn’t come across as an angry patient. You share so much data.

Maybe you can talk about a couple of the data points that you share in your book to really hone in on the challenges at hand.

Alyson: if you look at the big ones: heart disease. Women are less likely to be diagnosed when having a heart attack and treated with evidence-based medicine. They are less likely to undergo basic diagnostic testing compared to men which means they have higher mortality rates.

With just that one example, it’s because the public has been taught male patterns of disease. The messaging is that if you have a large elephant sitting on your chest that radiates down your left arm, it could be a heart attack. But that’s now how women present most of the time. Women present with shortness of breath or fatigue or discomfort. Women themselves don’t recognize it and delay care. When they finally go to the doctor, the doctor or nurse won’t recognize it right away. Testing isn’t ordered right away. They’re sent home and they get worse.

We have used men as our model for health and disease. We have this assumption that it’s “close enough” to apply to women. That has not turned out well for women’s health.

Georgie: one fairly famous example is Ambien: the dosing for men and women needed to be different.

Alyson: every medication, really, is at-risk for having unknown or bad effects against women. The real flagship for that is the sleep drug Ambien. This has been on the market for 25 years now. The studies were originally done in men and the drug was actually prescribed more for women because they have more sleep disorders than men. What happens is, after a drug has been approved and is widely used in the market, the only thing that physicians/pharmacists/patients can do is to go online and put in a report. So, the drug monitoring system looks at these. What they started to see was about 1,000 reports of women who, the morning after taking Ambien, had motor vehicle crashes related to being impaired. They woke up hoping to be well rested and then would get into the car and suffer from a motor vehicle crash.

I work in an emergency department. I see motor vehicle crash results. We’re not talking about a backache or a neck sprain. We’re talking about life and death. Real, traumatic consequences. What happened was the drug company started to look at this. They wanted to make a new formulation of the drug. They gave it to both men and women and then waited the amount of time the bottle says you should get sleep. Then they put men and women in driving simulation studies. These are the same type of studies we use to determine safe levels of alcohol in driving. The women did horrible in these simulations. They stopped and took blood serum concentrations of the drug and found that women had two times the concentrations compared to men, even though they had been given the same dose. Women metabolized it differently than men, leaving higher amounts in their system.

This demonstrates how important this is. We need to make sure that we test drugs in both men and women because the metabolism can be different. We want sex-specific dosing and to understand what side effects may be different.

Georgie: we can say basically that women have cycles and hormones but you also talk in the book about how women process things differently, separate from hormones.

Alyson: from the moment you take a medication, your body starts to break it down. It wants to break it down so that it can be absorbed and travel through your whole system. That medication will have its action. Then the body says, “ok, we’re ready to excrete it” and breaks it down in a different way. The liver enzymes and your kidney function tries to get rid of the medication. What we have found is that there are very important differences in every single one of those steps between men and women that can actually affect how the drug works, toxicity and side effects.

This is very important for many medications. For instance, the hormones that occur during women’s cycles can turn on or off certain enzymes. There are a couple of drugs that are used for seizure disorders. What we have recently discovered is that, during certain phases of the menstrual cycle, that particular drug may drop down and not be as effective because of hormone levels. What happens is those women are now susceptible to having a seizure during certain times of the menstrual cycle. But we don’t really take that into account. Instead, the woman will be told that she can’t drive or the dose needs to be increased for the entire month (which makes her more susceptible to side effects). These are things that we should be taking into account. Women have unique physiology.

Georgie: my passion for women’s health came in the 90s when the FDA started talking more about women taking part in clinical trials. Maya Dusenberry, in her book Doing Harm, talks about how that didn’t actually happen. From what you’re saying, it still hasn’t fully happened.

There are a couple more quotes from your book I’d love you to talk about.

One is, “we are no longer in the era of ‘doctor knows best.’”

The second is, “while I don’t advocate for self-diagnosis via the internet, having a baseline understanding of your current prescriptions and how they may function in your female body is a great way to start a conversation with your provider.”

What kind of research should a woman be doing to be prepared and ensured she’s not only on the right medication but the proper dose?

Alyson: I really do believe that women should do research, even with the internet or reading prescription package inserts. Women can take ownership of the accuracy of their own personal medical records. Because of electronic records, things are copy and pasted and shared across systems. If they aren’t accurate, you may not be receiving the correct care.

Do your own research and ask questions of your doctor.

Ask whether a medication is right for you as a woman and if your dose is correct. Feel free to inform your doctors and look at them as a very well-educated and experienced advisor. A consultant in your own healthcare. Advocate for yourself. Get second opinions if you feel that something isn’t taken seriously.

I also encourage women to make sure that they express their motives for the visit. Do you just want to be free from pain or a couple of hours? Do you want to be heard? Do you feel as though you might have cancer because of a recently diagnosed family member? Do you want a note for work or referral to a specialist? That will help open the dialogue between you and your “consultant,” to get more personalized care treatment.

Georgie: that’s such a fair statement, to look at your physician as a consultant. Especially if someone is a general practitioner, the amount of things they have to keep track of is immense. For specialists, there are still immense details. Physicians don’t have every medication insert memorized. Some will know more about different topics.

The internet can sometimes be frustrating, even for physicians, because someone comes in with different kinds of information. But it is also empowering.

Alyson: it’s also inevitable. I worked a shift last evening and this woman was very upset and I was talking to her about her condition. I asked, “what are you worrying about?” And she said, “I looked on the internet and I thought I might have this or that.” I want them to share that so we can talk about why I think they may or may not have those things. We don’t ask people to not do their own research or not look on the internet. That’s an unrealistic and unhealthy perspective.

Georgie: it isn’t necessarily always easy to conduct these clinical trials. We certainly don’t want to bash those who are manufacturing the product. Once, I had to put together a document for an FDA hearing because people in subpopulations were pushing the FDA to advocate for a certain kind of clinical trial. Essentially, the conclusion of the research document was that if every patient population was taken into account, clinical research would never be complete. We’re such a diverse population now that it’s impossible to find a pure sampling. I’m not minimizing the need for this but just to educate people that it’s not as straightforward as, “just put women in the trials.” I know from working on that project that it isn’t black and white.

More women should be enrolled in clinical trials and I hope that does happen over time.

Alyson: the FDA does have a demographic rule where they now require the listing of gender, race and some more qualities of those who are enrolled in clinical trials. However, there is no mandatory rule that says the study has to analyze the data differently based on sex. That’s part of the issue. We can't just sprinkle women in a clinical trial and then feel as though it’s appropriate. A male body may have a positive effect on a test and the female body may have a negative effect on a test. When you combine the two, you’re canceling things out.

Sex as a biological variable is a very important, scientific difference between men and women. From the cellular, chromosomal level this matters. For so long, men have been the standard and women have been a subgroup of men. Instead, we should see that men and women are unique biological categories. This different physiological makeup needs to be appreciated from the very start.

Georgie: there are some really interesting examples that you shared. One was that your husband, who is also a physician, hearing another male doctor talk about how he viewed female patients. It’s important to realize the underlying biases that impact healthcare.

Alyson: because my husband is also a physician, I get to see his perspective. He’ll come home with some cringe-worthy stories that fuel my passion. This occasion was a neurologist who said that there is an algorithm he follows. When someone comes in with subjective tingling, that this algorithm was that if the patient was a male, he would be concerned for a stroke and do a CT scan right away. If it was a female, he would just say it’s anxiety. This happens a lot. There is a bias. It’s there because women have so many conditions that aren’t fully understood. They’re given all of these wastebasket diagnoses like “syndrome.” That just means a collection of symptoms. Things like fibromyalgia and irritable bowel syndrome. They don’t fit into the paradigm that we have been taught. We spend 15-20 years learning to be a doctor and it’s on the job training. We’re looking at colleagues and learning how they view things. If our teachers come out and say, “that woman doesn’t fit any of the things that I was taught in medical school so it must just be in her head,” that gets passed on and on. There’s an emotional fatigue for women of not being understood and being passed off to specialist after specialist. That cycle of implicit bias has to stop.

Georgie: you talked to me previously about how you were giving a talk at a conference and very few people showed up. Now that you have your book and TEDx talk, people are beginning to attend your talks. What type of reception are you getting now from your colleagues?

Alyson: the shift is the data. Doctors, scientists and researchers are data-driven. So, over a decade ago when I thought this was so important and had a symposium that no one showed up to, I thought: “I need to start publishing a lot.” I knew I needed to publish scientific evidence that proved the reality of this. The community at large took note. It’s something that, now, is inevitable. You can’t un-know this now. Once someone reads or understands that there are differences, you can’t go back to ignoring that. I do feel as though it’s an inevitable change.

The NIH has a requirement for grant funding that sex is a variable. We are talking about high quality research. We need our research results to be generalizable to the people to whom they apply. It’s helpful that the NIH embraces this as a quality measure.

Georgie: you share so many data points and if I wrote it down correctly, it’s thousands of papers that you’ve reviewed. Female researchers are more likely to include gender differences.

Alyson: when I started to delve into this, I had a lot of colleagues who were interested in promoting women’s leadership. Making sure women were promoted and had equal pay. I thought, “I want to study women as patients.” That’s the other aspect but they go together really well. Women do think of women’s issues. When we promote women in science and medicine and give them the grants they need for research, they are more like to enroll women and to do sex and gender based analysis. This is twofold: advocating for one will help the other.

Georgie: what could (and should) women do so that when they go to the doctor they get the right care?

Alyson: I have a worksheet in the back of the book that helps them organize their medical history. That’s the first step: what tests they have, what doctors/specialists they’ve seen, any medication they’re on, smoking or alcohol intake, etc. Doctors aren’t here to judge. We want to know as much as possible about a patient.

Also, women can bring an advocate with them. Have someone else be there for you as a second opinion. For instance, if you are emotional because you’re in pain or because you are worried, it’s hard to communicate as clearly. Someone with you can say, “this is not how she normally is.” That can help put it into perspective for the physicians. They can also help remember things. It’s hard to remember everything a physician said.

Georgie: yes, owning your own medical record and using the worksheet. I love the idea of photographing your medications. If needed, or possible, keep track of the info in an app. For fertility specifically, a lot of women track their monthly cycle and take basal body temperature which can be helpful information. Any data you can provide the physician can help.

Alyson: smartphones make it much easier. I’m always looking at people’s photos. They take photos of their medications or their car after the accident. It’s all great information. The apps are a great idea as well.

Georgie: I’m sure we would agree that if a doctor dismisses that information, a woman should consider going elsewhere.

Alyson: it’s hard, when in an emergency, to dictate who’s caring for you. But, in general, if you don’t resonate with your general practitioner, that’s not the right doctor for you. This isn’t a dictatorship: it’s a partnership.

Georgie: the other thing I wanted to cover around doctor’s appointments, which is such an important nuance, is the “alarmist.” The person who has gone to doctor after doctor and is in a lot of pain or are struggling and they get to Doctor Number 7 or are in the emergency room and they’re very upset. Talk about how that impacts care.

Alyson: say a woman came in with some chest discomfort. One doctor says, “oh, that could be GERD or reflux so here’s some medication and go to the gastroenterologist.” The gastroenterologist says, “it’s not reflux so go to a cardiologist.” The cardiologist does tests and tries medication and says, “it’s not your heart, it could be your lungs.” Or maybe musculoskeletal and go see an orthopedic doctor. This woman hits a point of fatigue.

It can also happen on the side of a physician. If a physician walks in and a woman is beside herself and says that it’s her sixth time in this month, we are often like, “what can we do that’s different?” If someone has had all of that testing, what can be done? We ask ourselves that. I would often say at this point: “what do you hope to get out of this visit?” Instead of a woman feeling dismissed, they should be heard. I’m hoping that this improves care. Once we learn more about how women present with conditions, we may have more obvious choices. If those male-pattern conditions don’t fit, it becomes a guessing game. An educated guessing game but a guessing game nonetheless. It can be disappointing and disheartening for the women.

Georgie: what can a woman do in that situation? Not every doctor (I would guess very few) understand that first they need to hear a woman out. In your book, it almost seems to indicate that doctors will just shut down and not all be patient. It impacts the way they perceive pain. What can a woman do to have a more successful appointment?

Alyson: someone who has been going to many appointments and specialists needs to connect with a general practitioner who can look at it all as a big picture. That is the key. Sometimes, people in an emergency department have that ability. But you don’t always have that option. One main advocate needs to pull it all together.

Georgie: these have been some incredible takeaways. Before we end, are there other things that you think would be helpful for women to know?

Alyson: a lot of women who listen to this podcast or will read the book have some kind of role in a scientific committee or do peer review or on a board. It’s important that everybody looks at their own policies. Make sure that policies are inclusive. Be involved in enforcing the right policies. Even if you’re not a physician, women have many important roles.

Georgie: you’re an illustration of that, leveraging your research and passion to create something very credible to make important changes.

Alyson: there are some other books out there now that are chock-full of really important data. I really wanted my book to be from the physician perspective, to add to the dialogue.

Georgie: what would you want women to walk away with from this discussion?

Alyson: women should feel empowered to take control of their medical care. Welcoming the complexity of the impact of hormones on our health will lead to a greater scientific understanding of women and their reactions to disease. My greatest hope is that women will receive personalized, safe and effective healthcare.



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