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MedEd SYMPOSIUM SIWF/ISFM 2019Diversität in der ärztlichen Weiterbildung
Sex und Gender in der Medizin: Konsequenzen für die Weiterbildung
Prof. Catherine GebhardKlinik für Nuklearmedizin, UniversitätsSpital ZürichCenter for Molecular Cardiology, Universität Zürich
11. September 2019
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Gender: Socially constructed
characteristics of women and men
Sex: Biological differences
such as genes, sex hormones, anatomy, physiology
Sex
Gender
Foetus ChildGerm Cells Adult
Societal InfluenceNutrition Lifestyle
Genes
Epigenetics
Biological InfluenceSex hormones
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Study of how diseases differ between men and women in terms of prevention, clinical signs, therapeutic approach, prognosis, and social impact.
Gender-specific Medicine is a neglected dimension of medicine
Gender-specific Medicine
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Why is sex and gender an important subject in medicine?
Personalized Medicine
Molecular diagnosis and biomarker-based stratification
Severe sideeffects
Reducedefficacy
Excellentefficacy
«One-fits-all» Medicine
Severe sideeffects
Reducedefficacy
Excellentefficacy
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The differences…..
300g70-72 beats/min
257g78-82 beats/min
Source: Gettyimages.com
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Male patient, 72 years Female patient, 68 years
Myocardial perfusion imaging
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Meta-analysis comprising 48 studies, Br J Clin Pharmacol. 1998
The consequences of gender-unspecific medicine…U
nd
esir
ab
lesid
eeff
ects
pe
r 1
0 0
00
pa
tie
nts
Age
28
24
20
16
12
8
4
00-19 20-29 30-39 40-49 50-59 60-69 70-79 80+
Undesirable side-effects
285’862 Women
221’781 Men
Wang Z et al. J Clin. Med. 2018
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Example: Pharmacology
«…strongly indicates lack of therapeutic efficacy of the 2.5-mg/day mixed
conjugated-equine-estrogen regimen […] also suggest possible adverse
effects […].»
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• Between 2004 and 2013, women in the United States suffered more than 2 million drug-related adverse events, compared with 1.3 million for men, according to the US Food and Drug Administration (FDA).
• Out of 10 drugs removed from the US market between 1997 and 2000, eight were withdrawn because of side effects that occurred only, or mainly, in women.
US Food and Drug AdministrationUnited States General Accounting Office
The consequences of gender-unspecific medicine…
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49%
Herz-Kreislauf
Anderes
Unfälle
Atemwegs-erkrankungen
Example: Cardiology Cardiovascular disease is the most common cause
of death in women
Pan-European analysis, Eur Heart J. 2017
Frauen
Krebs
40%
MännerKrebs
Unfälle
Anderes
Herz-Kreislauf
Atemwegs-erkrankungen
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Berg J et al. Gend Med. 2009
The symptoms of a myocardial infarction differbetween women and men
0 20 40 60 80 100
>3 symptoms
Nausea
Vomiting
Abdominal pain
Back pain
Palpitations
Chest pain
Dyspnea
% of patients
Men
Women
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Women with an acute
myocardial infarction
experiencesignificant treatment
delays
Average treatment delays
Men: 1.4 – 3.5 hours
Women: 1.8 – 7.2 hours
Meta-analyis comprising 24 studies, Circ Cardiovasc Qual Outcomes. 2010
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Men suffering from acute stroke arrive earlier at the hospital than women
Study in 1134 patients, Stroke. 2010
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Only 18-24% of study participants in cardiovascular clinical trials are female.
The percentage of female cardiovascular patients amounts to 53%.
Pilote L et al. J Am Coll Cardiol. 2018Scott PE et al. J Am Coll Cardiol. 2018
Metaanalyse, Circ Cardiovasc Qual Outcomes. 2011
Women’s health research focuses on breasts and the reproductive system
Bikini-Medicine
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Example: Psychiatry
«Stereotypers of eating disorders inhibit the availability of evidence-basedtreatment for males and falls short of the successful management of genderspecific problems.[…]
«Resources are limited as treatment paradigms have been geared towardsfemales.»
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Depression is undergdiagnosedin men…..
Example: Psychiaty
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Alzheimer’s disease disproportionally affectswomen, but is often diagnosed late in women
Sundermann E et al. Neurology. 2016
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Women are more sensitive to pain……
Meta-analysis comprising 122 studies, Nature Reviews Neuroscience. 2012
Cold stimulus
Heat stimulus
Men more sensitive
Women=Men
Women more sensitive
P<0.0001
Number of studies
100 20 30 40 50
Men more sensitive
Women=Men
Women more sensitive
P<0.0001
Number of studies
100 20 30 40 50
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…and suffer more often from chronic pain
Meta-analysis, Nature Reviews Neuroscience. 2012
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…but:
79% of animal studies in Neurology are being conducted in male animals
Analysis of all experimental studies focusing on pain perception that were published between 1996 und 2005.
Nature Reviews Neuroscience. 2012
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Neuron
Dopamin, a neurotransmitter mediating pain perception, is being ingested twice as fast in female neurons as compared to male neurons
Walker QD et al. Neuropsychopharmacology. 2006
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Only 5% of studies are being conducted in female cells
Shah K et al. Am J Physiol-Cell Physiology. 2014Taylor KE et al. Biol Sex Differ. 2011
Male 20%
Female5%
Not defined
75%
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Example: Genetics
Nature Medicine. 2017
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Growing public awareness of the sex- and genderneglect in medicine
Gender-Medizin
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Sex and gender in medicine: vulnerable populations
Torres M et al. Ann Behav Ned. 2018Kandasamy S et al. Can J Cardiol. 2018Salami JA et al. JAMA Cardiol. 2017Batchelor W et al. JAMA Cardiol. 2017Todd JV et al. AIDS Patient Care STDS. 2017
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New regulations since 2016
• National Institutes of Health: issued its mandate for including females in vertebrate studies
• Canadian Institutes of Health Research: expects that all research applicants will integrate sex and gender into their research design when appropriate
• Gender policy committee of the European Association of Science Editors recommends that journal editors should ask all authors to report their results separated by sex and gender.
• The International Committee of Medical Journal Editors (ICMJE) integrated sex and gender analysis into its guidelines in December 2016
• The Lancet and Sex and Gender Equity in Research (SAGER) have published guidlines for authors and journal editors for evaluating manuscripts for excellence in sex and genderanalysis.
• UK National Centre for the Replacement, Refinement and Reduction of Animals in Research has issued guidelines calling for basic research to always report the sex of lab animals.
• Horizon 2020: sex and gender must be integrated into all stages of research and innovation
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Sex and gender in medicine: the other side
Delpech R et al. Eur J Prev Cardiol. 2016Tsugawa Y et al. JAMA. 2016Lee H et al. Can J Cardiol. 2019
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Yong C et al. JACC: Cardiovasc Interv. 2019
Sex and gender in medicine: the other side
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Science faculty’s subtle gender biases favor male students
Women
Men
Moss-Racusin CA et al. PNAS. 2012
Competence Hierability Mentoring
5
4.5
4
3.5
3
2.5
2
1.5
1
Sex and gender in medicine: the other side
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Summary
Limited knowledge and lack of awareness..….
• …..that sex- and gender-differences exist in pathogenesis, diagnosis, therapy and prevention of disease
• …..that sex and gender impacts the physician-patient relationship
• ….that gender impacts the training, mentoring, and career-decisions of residents
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What can we do?
Fix the knowledge
ResearchTeaching/Education
Patient Care
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How to implement this into clinical practice?
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Fix the knowledge: patient care
• Be aware that disease development, manifestation, and course are different in men and women
• Know about the demographic groups that currently have insufficient or suboptimal medical care
• Develop and implement gender-sensitive diagnostic tools and gender-sensitive treatments
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Fix the knowledge: patient care
http://www.isogem.eu
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Institute for gender-specific medicine
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Fix the knowledge: teaching
Single courses involving sex and gender medicine aspects
Multiple stand alone courses on sex and gender medicine
Integration of sex and gender
medicine in multiple teaching courses
Integration of sex and gender
medicine in all teaching formats
throughout the curriculum
Integration
into
assessment
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Fix the knowledge: medical education
• Provide information on gender sensitive disease manifestation and gender disparities in disease management
• Detect gender-specific problems in medical training and mentoring of residents
• Take measures to eliminate these problems:• Be aware of unconscious bias• Address a lack of support in the workplace• Specific mentoring needs of women and men• Flexible working hours and opportunities to align work and family• Support for returners after career breaks
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„Der Patient darf nicht als Neutrum mit männlichen Zügen behandelt werden“Vera Regitz-Zagrosek
Direktorin Institut für Gender-Medizin Charité Berlin
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https://www.med.uzh.ch/de/Nachwuchsfoerderung/Gastprofessur-Anna-Fischer-Dückelmann-2019.html
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Vielen Dank!