Previously unmentionable: A change in attitude about women's health care

In the blush of post-war 1950, women were silent about their bodies. Topics such as menopause and sexual health were rarely discussed, even in the exam room.

Gender-based treatment differences were not considered disparities. And, until recently, the understanding of the feminine experience with illness and disease generally came from studying men.

"The majority of practitioners at that time were men," says Sheila C. D'Nodal, MD, the medical director of South Nassau Women's Health Center in Oceanside, N.Y. "Perhaps because men were financially, socially and politically the dominant sex and women were usually portrayed as subservient housewives, medical complaints of women were often seen as a result of a woman's emotional natures and of lesser consequence."

But the times, they are a-changing. Actually, they already have. A historical perspective conveys how the women's rights movement and related political forces spilled over into the health care arena -- revising the way women's health is viewed by both medical professionals and patients alike.

It also reveals how women now make up a critical segment of the health care marketplace, both because they are generally high utilizers of health care services and because they often make the health care decisions for their entire families.

As a result, physicians must figure out ways to meet the needs of this patient population -- a challenge that often requires a different bedside manner and a heightened awareness of health care's gender gap.

The power of the pink

Women's health activism triggered cultural shifts on many levels. For instance, the advent of the birth-control pill ushered in reproductive freedom and even helped fuel creation of women's health clinics. More recently, women have backed successful drives to fund research for heart disease and breast cancer, shedding light on prevention and early detection. Their advocacy also led to policy changes to lengthen hospital stays and overturn managed care restrictions, giving rise to terminology such as "drive-through deliveries" and "overnight mastectomies."

One particularly poignant example: the fight to gain insurance coverage for breast reconstruction. "They said the breast was an organ with no function," says Christine Horner, MD, then a Kentucky-based plastic surgeon. "Yet they paid for penile reconstruction and penile implants." She considered this situation unacceptable and, in the early 1990s, became involved in organizing a grassroots campaign, founding the Women's Health Advocacy Project and eventually garnering support from the American Cancer Society, the American Society of Plastic and Reconstructive Surgeons, and others.

Ultimately, the Women's Health and Cancer Rights Act was passed in 1998. Because of it, all health plans covering mastectomies are required to pay for breast reconstruction.

But the coming of age of women's health is not only reflected in the directions of public policy. It also can be seen in individual behavior. Now more than ever, women are informed consumers -- they read, research and gather information from the Internet, from daily news, women's magazines, and even medical journals. Armed with data, they freely question physicians. At the same time, their presence at the other end of the stethoscope has increased, too.

"More women are in medicine and interested in their own bodies. Issues such as menopause, PMS, incontinence, breast cancer, sexual dysfunction are at the forefront of research efforts," Dr. D'Nodal says. "Women are taken more seriously, and their medical issues have taken on more importance."

These issues also lead to time-consuming conversations between physicians and female patients -- which creates a new dynamic for doctors. "With the skyrocketing costs imposed on us, complying with managed care requirements and increasing malpractice costs in the face of decreasing reimbursements, it becomes difficult to give sufficient time to the real mission of our profession, which is to prevent, diagnose and treat disease," Dr. D'Nodal says.

Not taking this time can take a toll -- one that Annapolis, Md., internist Jacob Teitelbaum, MD, says is important to avoid. In medical school "we were taught that if we didn't know or there was no clear pattern, their hormones were probably out of whack," he says. "Women are now saying, 'No, that's not acceptable.' In the past if you didn't like your doctor you were out of luck. Now women are increasing the competition -- they are voting with their pocketbooks."

Don't forget physiology

But the specific needs women bring to the doctor's office also stem from the fact that there are true variations between the sexes in terms of how disease and illness manifest and present. Women's symptoms, for instance, are sometimes more vague, or simply different than those of men.

"Women visit the doctor more frequently but are less effectively treated," says Marianne Legato, MD, an internist and professor of clinical medicine at Columbia University in New York. "They are not just smaller versions of men."

Communication style adds to the complexity. "Women tell a less concise story. They digress and often dismiss symptoms as not serious. Sometimes they say to the doctor, 'Maybe I bring this on myself or maybe it's in my head,' " Dr. Legato says.

Take heart disease. Doctors and patients often attribute chest pains in women to noncardiac causes, even though heart disease kills a half-million women each year.

"Attitudes are changing, but there is still a gap," says Pamela Marcovitz, MD, a cardiologist and director of the Women's Heart Center at Beaumont Hospital in Detroit. "I think part of it is the way women talk. They often focus on how it affects their life. A lot of busy physicians get annoyed when they start talking about the dog or shopping. ... They want to cure them and move on."

And, although many experts pinpoint improvements in the understanding of women's health, statistics demonstrate that much more still needs to be done. According to Making the Grade on Women's Health: A National and State-by-State Report Card released in May by the National Women's Law Center and the Oregon Health & Science University, the federal health policy agenda has not advanced as it should.

For example, although 43 states now meet national goals for providing mammograms to women age 40 or older, only three states meet national goals set for providing Pap smears, and only 19 meet the national benchmark for colorectal screening. Additionally, the prevalence rates among women for diseases such as diabetes and deaths from coronary heart disease continue at unsatisfactory rates. Other concerns cited in the Report Card have to do with controversial issues, such as the first federal ban on medically approved abortion procedures signed into law in 2003 and limits imposed on funding for family planning. They also note a troubling statistic: 16.5 million women in America do not have health insurance.

Relieving the tension

Efforts by patients, advocates and health professionals to do better in regard to these shortcomings have, in some ways, created a new landscape for physicians to navigate. Doing so is no simple proposition.

It's not just women who are changing. Mary Frank, MD, says doctors of her generation are behaving differently, too. "Women are not as hesitant to bring things up, and doctors are more likely to see it as a partnership," says Dr. Frank, president elect of the American Academy of Family Physicians.

"It's important that patients feel comfortable asking questions," she says. "They have the right to ask, and one would hope as you have an ongoing relationship, it's easier to ask the hard questions."

Nonetheless, Dr. Frank admits that these kinds of exchanges can kill a doctor's schedule -- and create tension. "Patients want to know all the pros and cons. There are more demands on the doctor to participate and compromise," she says.

And when there's a waiting room full of patients, it is not always possible. "For me and others, we want to give patients options, but the time and economic crunch makes it more challenging," she says. "In the future we need to look at ways to do it differently."

In a sense, it requires thinking out of the box. A group of seven major national family medicine organizations have undertaken a collaborative effort, the Future of Family Medicine Project, to explore approaches that might help doctors move in this direction. The idea, of course, is to arm physicians with ways to improve the quality of care delivered to all patients -- men and women.

For now, though, it is clear that changes in how women think about their own health will continue to affect the doctor-patient relationship. Topics once unmentionable are now out in the open -- everything from birth control to pelvic pain and fertility problems. Dr. Frank sees this level of confidence everyday as patients bring up concerns in the context of things they have already discussed among friends. "I realize this is now lunchtime conversation," she says.

It is a reality that has, indeed, triggered a different set of exam room expectations. And many physicians consider these changes positive. "Perhaps this voice has helped to open the communication barriers of past generations," Dr. D'Nodal says.