Women and Pain: The Bias that Hid My Broken Bone
The grizzled old ski patrol guy looked down on me and asked if I could put any weight on it.
“No, I said, “no way.”
“You sure? You’ll have to go down in the sled then.”
This did not make him happy. I got the impression that he thought the sled ride was probably unnecessary. I wasn’t happy either. On the last run of the day, just before 4 pm, I had taken a hard fall about half way down the mountain. My left knee was wobbly and throbbing.
The ski patrol guy earned my respect on the way down. Straight down the side of the trail in a snow plow position, holding me and the sled behind him with only the strength in his thighs. He stopped at one point to let me know he was going to have to go fast up ahead so that we could make it across some level terrain without stopping. We flew, with me desperately holding onto the sides, thankful for his warning. He brought me right to the door of the first aid lodge.
“On a scale of 1 to 10, with 10 being complete agony, how does your knee feel?” he asked.
I hate that question. Pain is such a difficult thing to convey. Health care providers ask it to give them some relative sense of severity but everyone’s 10 is different.
Anyway, my knee was really painful, so I said, “it’s about a seven.”
“A seven?!”, he gasped. “Ten is agony and your knee is a seven?”
Feeling chastised, I wiggled my foot a bit and replied, “well maybe it’s a six?” Was there a right and a wrong answer?
While his young assistants shared the ski patrol guy’s illustrious history with my skiing companions, (he’d lived on the mountain most of his life, been doing this job for many years) he began poking at my knee.
Does it hurt here? No.
How about here? No.
Here? Yessss! It hurt most right below my knee cap.
“Well, I’m no doctor but I know one thing — your leg’s not broken!” he laughed, like the very idea was crazy. “I’ve seen everything. You’d have jumped right off the table.” Everyone chuckled.
My boots were removed, the ice pack was applied, the paper work was completed. My rental ski equipment was gathered and returned.
The ski patrol guy’s parting instructions were “keep ice on it and see if you can make it through the night. If not, go the ER. Otherwise have someone take a look at it tomorrow.”
But before we left he had one more question. “You said the pain was a 6 before. What number would you give it now?”
“A six?” I squeaked.
“Really? It hasn’t gone down at all?!” he asked, shaking his head.
A pair of old crutches appeared to help me hobble to our car in the snow. As I was helped out the door by his assistants, the ski patrol guy pulled my partner aside and told him, “just keep ice on it as much as you can, she’ll probably be fine in the morning.”
The pain woke me in the middle of the night. I downed some more Advil and we refilled the bag of ice. I couldn’t get comfortable. My knee ached, but who wants to get out of a warm bed in the middle of the night and go to the ER?
In the morning we used the hotel room’s desk chair to roll me to our car in the garage. We decided we might as well get my leg examined at home, in our local medical network. We loaded up and six hours later arrived at our hospital’s ER door. They took me right in for an x-ray.
“Yup, it’s broken,” the nurse practitioner said. “The tibia. Right below the knee. Must hurt like hell.”
“It’s a 10,” I said.
It wasn’t until I had been in the car heading to the ER that I could articulate that I had felt dismissed and discounted by the ski patrol guy. I had been too distracted answering questions, responding to instructions, dealing with my pain, and fearing for my potential future, to push back on the guy’s minimization of my pain estimates. I wanted to have asked, “Who are you to tell me how much pain I am having? And if you’re not going to believe me, then why ask the question?”
I realized I had just bumped up against a common experience among women seeking health care: gender bias in the assessment of women’s pain. Studies show that male and female health care providers both have a significant gender bias in how they assess pain in male and female patients. Female patients are consistently perceived to be in less pain than male patients who report and exhibit the same intensity of pain. The bias may be due to the (false) perception that women are more expressive about their discomfort, while men are supposedly more stoic when in pain.
This bias results in
· women being less likely to be offered pain medications
· women being more likely to be considered emotional, hysterical, or accused of fabricating pain
· women’s pain being more often attributed to psychological causes
Most importantly, these biases impact diagnosis and treatment. Studies have shown that women:
· face longer waits to be diagnosed with cancer and heart disease
· are twice as likely as men to be diagnosed with a mental illness when their symptoms are consistent with heart disease
· are treated less aggressively for traumatic brain injury
· are often prescribed less treatment than men and wait longer to receive that treatment.
In my case, if the ski patrol guy had taken my pain assessment seriously, he might have sent us straight to an ER where the break would have been identified more quickly. In that case, I might have been prescribed pain medication to help me through the night. Also, I would likely have been given a leg immobilizer to help keep my condition from worsening. My fracture was situated in the tibial plateau but the bone was still in place. The danger was that the bone would crack further before I got into surgery. Once I saw the orthopedic specialist at home, he rushed to get me into the operating room.
My story did not result in further damage, but many women suffer psychological harm, delayed or inaccurate diagnoses and treatments, bodily harm, and premature, unnecessary death. (You can read some of their stories in my references listed below.)
Unfortunately, people of color, people with low income, geriatric patients, and LGBTQ+ people also face the bias against self-described pain intensity. It’s past time for health care providers to identify, own, and overcome their biases.
What should we do if we experience bias in our own health care experiences? Often there is little we can do beyond seeking health care elsewhere. The burden to change the system should not fall to those who are its victims. Luckily, the recognition of bias in patient care is becoming increasingly acknowledged. Courses and professional education in anti-bias patient care practice are being implemented in professional training and academic institutions.
However, if you are able to articulate either at the time of the incident or afterwards what occurred and how you perceived it, and if there were any consequences, send your story to the health care provider or to the practice or company they work for. Many people are unaware of the biases they have, especially when they are based upon common assumptions that exist in our culture.
I’m sending a copy of this blog to the snow patrol guy. I don’t think he’s aware that he has a bias against women’s assessment of their pain. I think he is otherwise very good at what he does and I very much appreciate his help on that mountain. But I’d have to only give him an 8 — 2 points off for bias.
