Sexist Description In Surgical Textbook Highlights Bias In Medicine, Physicians Say

On Sunday, June 28, medical student Sam Finlayson took to Twitter to call out a sexist description in a widely available medical textbook. The description of Cushing disease in Dr. Pestana's Surgery Notes described the effects of the disease turning a "lovely" young woman into a "monster" and saying if a patient turned out not to have Cushing, she was "just a fat hairy lady."

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The tweet quickly attracted nearly 1000 likes and hundreds of retweets, along with dozens of comments, mostly from medical trainees and professionals expressing confusion and outrage that such a description could be found in a modern-day medical textbook.

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Not all commentators felt shocked, however. Some included pictures of sexist prep test questions they'd come across in their studies. "This is not surprising because I think we see examples of this everywhere, not just in medical literature but in our culture," said Lillian Erdahl, MD, associate professor of surgery at the University of Iowa Health Care, Iowa City. "We have so many cultural expectations of women's bodies, and so then it's not surprising that that would be translated into the medical text."

This description is particularly problematic because it conveys a "paternalistic, insensitive, and offensive" approach to describing and diagnosing patients, Arghavan Salles, MD, PhD, scholar in residence at Stanford University School of Medicine, California, said in an email. It's an example of sexism and gender bias in medical education and culture that affects both patients and providers, said Erdahl.

The textbook publisher, Kaplan Test Prep, apologized for the description in a statement to Medscape Medical News and pledged to correct it in future editions of the book.

'Damaging to the Profession and Patients'

Gender bias and sexism in medical textbooks have made the rounds on social media before. In fall 2019, a tweet about a surgical textbook used in Australia went viral (with 2500 likes and 1600 retweets) because the book included pictures of scantily clad female patients staring seductively into the camera to illustrate several common medical exams. Researchers have also pointed out the dearth of women and racial minorities depicted in popular anatomy textbooks, with the vast majority of illustrations featuring seemingly young white men.

The lack of professionalism demonstrated in the Cushing passage is particularly troubling, according to Erdahl and Salles. "We need to be teaching students about empathy, respect, and equity. Instead, this passage suggests speaking about patients in derogatory and condescending terms is appropriate," said Salles. "In an educational context, this type of writing could empower trainees to speak disrespectfully to and about their patients, and that, of course, is damaging to the profession and the patients of those students."

Salles said she was also really struck by the obesity bias and use of inappropriate, unprofessional descriptors in place of respectful, people-first language. "Overall, the description shows a disregard for the patient as a human being and instead objectifies her as being defined by the diseases that affect her," she said.

For female medical professionals, the description is one example of the kind of bias and harassment ubiquitous in training and medical practice, said Erdahl. Although there are more women going into general surgery than ever before, "the culture of the field is still largely driven by men," said Salles. The effects reverberate from training, where research has found male trainees are more likely to receive written evaluations containing standout words like "outstanding," all the way up to leadership, which is dominated by men, she said.

"Both implicit and explicit gender bias negatively impact the career opportunities of women," said Salles. "Microaggressions constantly remind women that they don't fit in."

Kaplan Test Prep, the textbook publisher, replied to Finlayson's tweet on Monday, saying, "We appreciate comments about our materials and encourage dialogue with the community we serve." The company also said it had reviewed the description of Cushing disease with the author, Carlos Pestana, MD, PhD, "who agrees with the concerns raised, as do we." Medscape Medical News was unable to reach Pestana through the University of Texas Medical School at San Antonio, where he is professor emeritus of surgery.

"We sincerely apologize that this description was included," a spokesperson for Kaplan wrote in an emailed statement to Medscape Medical News. "Sexism in medicine is a serious issue and we will certainly correct this language in the next edition."

Although the response from the publisher is a good start, it doesn't go far enough, said Erdahl. Authors and publishers should go through all of their textbooks and prep courses with "a 2020 editorial eye" to try to find other issues, she said. Kaplan could issue a correction to everyone who has already purchased the book, she said. Going forward, integrating more women and men who are educated on these issues in the editorial process would help address biases and ensure future language is inclusive and supportive, said Erdahl.

A representative for Kaplan told Medscape Medical News via email that it would not be possible to contact every individual book buyer. In response to a question about reviewing other textbooks and materials, the representative also noted that course materials and books undergo continual review by multiple reviewers, and the publisher wants to be sensitive to concerns and issues raised by students who read Kaplan books. "In such cases, we make every effort to reevaluate and when necessary, make a correction," the spokesperson wrote. "This will be an ongoing process."

The story here goes beyond just one textbook and points to the need for "broad sweeping cultural change," said Erdahl. "It's not about any one individual, it's about the sort of inherent biases that we've all learned that we need to make apparent and change."

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