Welcome, everyone, to our second AOFAS on the same page, where we're going to be discussing the book, Doing Harm, the Truth About How Bad Medicine and Lazy Science Leave Women Dismissed, Misdiagnosed, and Sick. I have a little housekeeping. These are the disclosures of our faculty members who are going to be giving the overview of our book tonight. Thank you to Stryker for supporting the AOFAS DEI initiatives. This is a reminder that on Wednesday, October 12th at 8 p.m., we are going to be doing our next AOFAS on the same page in collaboration with The Root Jackson. We have yet to identify the book or if it's a journal club, but stay tuned. Lastly, this is our speaker, our first DEI speaker, Tara Hauska, who is a tribal leader, land defender, and environmental rights and Indigenous rights advocate who will be joining us in Quebec. Please be sure to register. I am going to start. Again, we're in the title, but it's by Maya Doonesbury. She is actually a feminist author. She came up with this book as she was diagnosed with rheumatoid arthritis at the age of 27 and was interesting in that she found that it affected millions of Americans, but it definitely lacked awareness in this country. As she further researched, she wanted to write a book that showed how gender biases affect the care our patients receive and that this bias is unconscious and systemic. Even women physicians are not immune to it. I definitely learned a lot from this book. It definitely was a little denser than our last one, as the committee was just discussing, but nonetheless, very educational. She further states that there is a problem. The problem is a knowledge gap that every, or excuse me, the average doctor does not know about a woman's body and health and how it affects it and the problems affect it. I'll be discussing that a little bit more. Then the trust gap where women are not believed when they discuss and report their symptoms. There's definitely more that she goes to into the introduction, but in lieu of time, I'm going to jump right into chapter one, which is the knowledge gap. Again, definitely eye-opening for me. What I found was there's a lot of talks about the various policy changes that occurred during the span of between the 70s and 90s, but basically she wanted to make the point that the knowledge gap is lack of research focused on women's health. Women are left out of many of the largest and most clinical studies. This was one where I was like, I never thought about that, that women were not included in these big research studies that make some of our treatment options present today and leaving them out is definitely leaving out a big key of how does that research actually affect women as a group? The other thing was the FDA had a policy forbidding women of childbearing potential from participating in drug trials. This was found that any woman who from reproductive age was not included for fear that it would mess up their reproductive system, but at the same time, men were not included yet they have this saying it could affect their reproductive aspects as well. Definitely interesting that we were protected even though women who were lesbians, who were single, who were in relationships or partners who had vasectomies, these women were not able to participate even though they were not actively looking for childbearing. Tanya, it's interesting to me when I was reading this chapter, we are so obsessed with women's reproduction. It's just like, oh my goodness, women can have babies. I guess obviously it's clicked this week, but while I was reading this book, I just was like, man, we are really obsessed with that. We, for fear of a possible reproduction issue, we're not going to even just look at it. We're not, we just not going to have anyone, we're not going to talk to the women and say, hey, are you, are you pregnant? And can we test you for pregnancy? And then, you know, ask you to be enrolled in the study. Like there's this whole kind of paternalistic thing that we must not, you know, we can't involve women in the discussion. We just won't include them. And I just, I had never really kind of brought it home like that until I really started going through this chapter. I was like, how can we really be doing research and giving medication and surgical and just, and not, you know, purposefully look at over 50% of the population? It's just unbelievable. I agree. I definitely thought it was eyeopening when I was, you know, reading it and I was like, huh, I never thought about that either. And most of the time we think of women's health, we think of just the reproductive aspect when there's actually more to women's health. And this is just reproductive health is just a subset. But just to chime in one more part on that, you know, Gary, that's so true, but it's the obsession is not in protecting women's health, it's protecting fetal health. And so the reason women aren't included in the studies is not because they want to protect a woman, but they want to protect the unborn child or the potential of the unborn child. So it's a misnomer to call it women's health. It's actually fetal health and it's not protecting women in any way, shape or form. It's really protecting this concept of the child that she may bear. Yeah, Holly, I think that's a great point. The other thing that I found fascinating was I think what she referred to as bikini medicine is, you know, with women's health, we what we're really focusing on are the breasts and the reproductive system. But and I think this was an eye opener for me because that's what I've always sort of associated with women's health as well. But then you start to read this and you go, oh, my gosh, because of the monthly cycle and all the different hormones and everything that we have in our bodies, it's not just the bikini that we need to focus on. I mean, this affects, you know, our cardiovascular system, our respiratory system, our endocrine, I mean, like everything. And that was the biggest eye opener for me as I'd always been a proponent and a big fan of women's health and trying to. But I realized I sort of fell into that bikini medicine mindset as well and never really considered the whole body. And I think that that's something that we've probably all done without even thinking about it. Yeah, no, I agree. And what I think was striking was, you know, some of the, you know, statistics that she brought, you know, brought up in the book and how new it is, like in the late 80s, which is not that long ago, only 13.5 percent of the NIH funds were research that was unique and relevant and prevalent for women, but only 13.5 percent. That just seems wild when, you know, we make up 50 percent of the country. And I found that very striking. And then in the 90s, the NIH formed the Office of Research on Women's Health and mandated that women be included in research studies because they were not. And it was, you know, at first suggested, but then it was, OK, we need to have women included so that we can take these research, you know, findings and apply them to not only women, but also people of color and not just the base it off the 70 kilo, 70 kilo white male that a lot of the research is based off of. It was something I never really thought of. And even the subset where she talks about female mice in the basic science studies, it's all male mice. And I was like, wow, as a woman, I never thought about that. But how critical and how important that is to get these findings that are applicable to both men and women. And that basic science, you know, I guess it's one of those things where you just, you know, you don't even think about it. No one even until until like a book like this or discussions like this, I just as a male, you're just not going to think about it. And, you know, like, well, this is what the studies say. And, you know, the thing about it is a 70 kilogram person, which isn't even me at this point, you know, and then just to to kind of extrapolate all these things that we do and have these ranges of how we treat and to not include. 50 percent of population or more at this point is just again, bring home. Yeah. And then not only that, you know, it also applies to pregnant women. You know, pregnant women are not included in research studies because of, like Holly said, you know, they're worried about the fetus and how I think there's only eight FDA drugs that are approved for, you know, pregnant women. Yet pregnant women suffer from hypertension. Pregnant women suffer from diabetes, but yet they're not included in that research. And, you know, we need to be able to ask them and say, you know, you're you're well informed. You should be able to state whether or not you want to be included in a research study. And they're just like that paternalistic viewpoint. We're going to protect them and the fetus. And that definitely needs to change and how slow the change is. I think that's another thing to to discuss is, yes, we have these best intentions and it's going to be a little bit before we're going to see that that change. The one thing I also liked that I read in the study was there was basic science journals who are not required to report on gender and minorities with their results. And now I think there was like 32 peer reviewed journal articles or journals that were mandating that that be reported so that we do have that that, you know, that data. And it's not just, you know, one sided. And then lastly, is changing our medical education. You know, it's how many medical schools teach women's women's health. It's definitely not something that is taught. And it needs to be so that we can start implementing these changes. I'm trying to remember being taught it. You know, you might get some in, you know, obviously OB-GYN, but not any other specialty that I can think of, maybe a little bit of cardiology. But, you know, not these other like rheumatology, those sorts of things where we're missing, where women are more afflicted with these different types of diseases. I think she points out a lot. I mean, throughout the book, it's a constant theme of how much is missing in the medical education. And we definitely learned that in our prior book club and talking about race, you know, the just the sort of average person, as Gary said, is a 170 pound white male, and that accounts for only a small portion of the population. But, you know, you're it's a it's a theme throughout the book that we need to change our medical education in order to sort of change perceptions of doctors going forward. I mean, I just think there needs to be we need to completely revamp things, just the way that we are taught from, you know, we could talk about in terms of orthopedics as well. But there's, you know, you when you talk to do a hip replacement, you know, I'm sure there are differences. And then I think in terms of marketing, you know, they may market a hip replacement saying it's like it's for the woman or whatever, because it may be smaller or smaller incisions, but it's not necessarily I haven't seen any study. And I'm not reading the hip literature. I'm just any study that has specifically said that this was done on such and such number of women. And this is what we've seen. I mean, if any of you have read a study like that on almost anything, whether it be, you know, ankle fractures or what have you, it just doesn't exist. And I just think that we have to think about, I mean, that first part in itself, talking about the structural issues with funding and research and the way it's taught medicine, it's just never going to change. And when I think about women's health and completely wrong, all I can think about is an OBGYN rotation. And to Holly's point, I only think about it in terms of a woman's uterus, you know, and how that, and when I think about medications and I'm prescribing them, if a woman, I do think about, well, is she pregnant or should she get an x-ray? And really it has, it's all about, I mean, really that was enlightening really for you to say, Holly, it's really all about fetal health. And I think about just in general, and I think that's part of the problem with how we approach it in medicine. And so your first day of medical school, if you were to have it not presented as women's health, but as health of humans, I think that that is when you're the most impressionable, you're super excited, you want to read and learn everything. And I can just remember instructors just kind of when fibromyalgia was just coming out and you would just hear like, oh, she's just complaining. Oh, she's, you know, she's just, you know, again, the dinner party thing. I mean, I can hear professors say, ah, she's just rich and, you know, kind of confirming things that, you know, biases that are out there throughout the world. And I just think it's got to change. And I know when it does change, there's going to be someone that's going to say, well, what about the guys, right? You know, we got to learn about the guys. And I was like, well, we always learned about the guys. There's a, there's a dearth of information, you know, in terms of how things affect women. And, you know, if I were a woman going to see a doctor after reading that first part, I'd be like, he knows nothing. He or she knows nothing about my body. So I think that as we enter into part two, I think unless Rob, are you going to add something? Can you speak? Oh, I guess not. So, sorry, I'm here. A little technical problem. Go ahead. You guys want to add something? I don't want to take a bubble. What I noticed in the first part important was two things. One was, I think traditionally the infant mortality rate should come down, but I think it is going up. And that suggests about how women's health is being taken care of. And then when I was in medical school, you always knew women have longer life expectancy. But apparently the gap is getting narrower from men to men. So those are the two really points which I thought were really striking upon the fact that the woman health care is so important and things need to change. Yeah, I mean, there's a good discussion. So I don't want to get too bogged down in the review of that second chapter. But she went into talking a lot about the origins of hysteria and medical issues assigned to women throughout the ages. And I've heard the word hysterectomy, I don't know how many millions of times, but my Latin is not good. And so it was nice for her to explain the origin of hysteria as hystero, the Greek word for uterus, just kind of showing how this comes down through the centuries. She gives a historical perspective of kind of how that was used as theory for essentially unexplained symptoms or unexplained diagnoses, kind of morphed into thoughts of nerve disorders and maybe a combination that the women are more susceptible, if you will, to the unexplained symptoms and fragile because they have a uterus, if you will. And how that was used to keep people out of keep women out of positions of authority and power because it's fairly convenient to say, well, if someone's menstruating or pregnant or in menopause or what have you, they might suddenly go into hysterics and we can't have them as a doctor or a surgeon or a community leader or what have you. And so it's just kind of built upon itself. I think it was and that next kind of prevailed even into the mid 20th century until we started to get a little bit better at medicine and we started to come up with more diagnoses and hysteria instead of being a junk diagnosis went to the wayside a little bit. But she talks about how that morphed into diagnoses of somatoform disorders and conversion disorders and things like that. But I think the concept of the medically unexplained symptom, you know, you mentioned fibromyalgia and, you know, I think you could, you know, in my practice as I'm reading this, I'm thinking, all right, well, I know how I react when I look on paper and it says fibromyalgia or CRPS or neuropathy or, you know, six back surgeries or what have you. I, you know, I know that conjures an image in my head and is already going to bias me to wonder if there's an orthopedic problem and am I going to be able to help that person. You know, maybe if I'm looking at a referral, you know, am I going to even think that I'm going to see that person in the office or am I going to just write them off because they've already got a label and I've already decided that there's not something that I can cut out, if you will. She talks about that, not to make light of the subject, but she's talking about people getting labeled and having that being hard to get rid of, particularly if it's a psychiatric disorder. And it brought me back to that Seinfeld episode where Elaine gets written up as a difficult patient and it travels throughout her life from doctor to doctor. And, you know, I think that happens. Once that goes in the chart, you know, people have a hard time getting rid of it and leads to doctor shopping and that type of thing. So, yeah, that's where it kind of hit home for me is I know I don't think I've ever diagnosed someone with hysteria, but I've certainly looked at someone and I think I'm pretty good about saying, you know, I believe you hurt and I, you know, I believe there's a problem. I'm just not sure what the answer is right now. But I'm probably not good about diving in and looking to see is it an autoimmune disorder or what have you. I think, you know, Gary is better than me at kind of running down that road. But this was more than theoretical for me because I could see these kind of real life instances occurring in my practice. There's been a wealth of new literature on how to predict which patients will do well and which patients will do poorly. And a lot of it has been spearheaded actually by someone who I would call one of my mentors, David Ring, who was a hand surgeon at MGH and is now at Dell Medical School. And I think that the premise is really solid where you're trying to figure out who can we identify ahead of time as people who won't do as well with surgery. And we know that patients with anxiety and depression, you know, stereotypically and actually, you know, through the research we've seen, they tend to not do as well as patients without those psychiatric diagnoses. And that there's a tendency to, that people catastrophize pain and who are those people? But I think that, you know, and I always really bought into that and I believe it, I do believe it to a certain degree. But there is something to be said that somebody with chronic pain is going like, how depressing is that? You know, that would depress me if suddenly I couldn't do the things that made me who I was, you know, whether it's working or exercising or being able to appreciate life in the way that I knew it, I'd be pretty damn depressed. And so, you know, I think we need to really be careful of those labels and flip it around and think, well, maybe these people are anxious or depressed because they've been blown off by doctors, because they have chronic pain that's never been addressed. And you can imagine the anxiety of going into a doctor's office when every single time you go in, you're told either you're a liar or you're not believed, or you're told that you're hysterical. You know, whatever the word is for it now, you're nuts. And we say that all the time. Oh my God, she's nuts. She's nuts. She's nuts. But you know, this really made me think about the way that I perceive that list of medical problems. And I'm going to try to get away from that and just sort of see the patient without those preconceived biases. I think it's a combination, sorry. I think it's a combination of that we in medicine keep thinking that we are traditional, but I think sometimes we're crossing the line with being outdated and being so afraid to look more beyond that point. I think before we only have literature based on males or we were not exposed to many different things because everything with women were covered and it was like hidden. It was like, you know, like a topic and we just stay with that data. And then when we're going to try to apply things, I think it's wrong because obviously there are differences between the two of us. And I think that's why we need to be more open to be able to explore more, to acknowledge that we are two individuals with different characteristics, face of disease, how we face things. And when we look at that, maybe we'll be able to assess women in a more accurate way because we will use information that is based on what they have. I mean, I agree with that. You know, I just keep going back to the fact that when, you know, if you see someone in the office and then, you know, they even said in the book, you know, doctors want to make people feel better. And when you have someone that has a diagnosis that could be chronic pain and you're just doesn't seem like you're able to help them, you know, we kind of become frustrated and then almost sometimes it becomes an ego thing within ourselves because we want to fix things and we think we're smart. And so then we kind of put that on the patient when it's not really fair. And then if you look on the chart before you even walk in and some of us, you know, end up seeing the more difficult cases anyway, you're like, oh my gosh, I just can't see an ankle sprain, right? You're like, you know, this person has fibromyalgia and then they have lupus on top of it. And then, you know, they're like, hey, you want to fix my blood? And you're like, no, no, I don't. You know, like you just, and that's not fair, right? I mean, they have, you know, and if a man comes in with complaining of pain, you know, it's almost like he must have pain. He's here because men don't go to the, you know, men never come to the doctor. So when he's here, we have to listen. And then, you know, but then the numbers aren't showing that to be true. That's just a misperception. And so I think that's where, you know, we as physicians have to look at books like this, because we're not learning it in, you know, learning it in medical school. And a lot of us are far away from medical school, and this isn't necessarily something that is being brought up. It is, or maybe we're not even listening. And I think that's the number one thing that I kind of found in general, as I kept going through this book was, we're just not listening to women. We're just not in any way, unless they're pregnant. Once a woman becomes pregnant, then oh my goodness, we must listen now. Because there's, again, Holly's point, there's a baby coming. But if they're, you know, as we get into, you know, the part that I went over autoimmune disease, and they talk about thyroid disease, and how the normals and how those are adjusting, doctors can't even figure out what is the normal, normal range. But if she's pregnant, we'll just treat it just in case. And I just like, oh my goodness, we're so bad. There's, and you can even, you can even look at this at diseases that are quite obvious. So all of us see bunion patients, 80% are women. And yet somehow there's this narrative, that we shouldn't fix a bunion until it's so bad that a woman can't put a shoe on, or that somehow it's an acceptable answer to a woman, that you, I'm sorry, you just have to wear a sneaker for the rest of your life. And I always use the analogy, can you imagine if a man came in and he had a neck irritation, and we said to the man, you can never wear a tie. And you have a businessman, he said, well, I need to wear a tie. It's part of my job. I have to look professional. I'm sorry, you can't wear, you can't wear a tie. That would never be an answer. And so you're the dismissal of woman's pain because it's on her foot somehow always really irritates me until it's to the point where I can no longer do it minimally invasively, or they have, you know, five, four hammer toes and the surgery is terrible. And so I, the, that whole, that whole narrative needs to go away. If a woman comes in and she has a mild bunion and she has pain, she has pain. She doesn't need to have a crossover toe deformity to somehow warrant surgery. And I find so many women come in and they have to justify the fact that they're even having the discussion about pain. And I say, don't worry. I believe you. You've got a severe bunion. I'm so ready to fix it. You don't have to talk me into it. Um, but there's this feeling that, you know, Oh, I shouldn't be complaining of this pain. Cause it's only my foot. And you'll, I, I feel great when I wear, you know, a shoe that's for four sizes, too big and extra wide, but you know, when I have to go to the office, it's really embarrassing. And so, you know, that's just a, that's just a whole other narrative that, that needs to be changed within our world. Or I love summer season. Cause I can wear my sandals and have more room, but the minute fall hits, then you have to go back into closed-toed shoes and my pain returns. So that's the other thing that we always hear with our, our female patients with bunions. Yeah. And somehow they don't have pain because yes, true. When you wear a size EEE, that's not painful. Um, true, but I don't know. It's just, it's just another dismissal of pain. Yeah, I agree. I think, I mean, yeah, just as was already mentioned, but, uh, one of the biggest things coming from this book was like, gosh, we, we, as Gary was saying, we just don't listen to them. Uh, I found, you know, throughout the different stories, um, these women were being labeled with, you know, panic, panic, attack, anxiety, whatever it is. I mean, from the very beginning without, um, I mean, they could barely even get one sentence in before they were labeled as that. And, um, and so just the, yeah, the lack of respect, um, just the, the not listening. Um, and then, you know, the author spoke at one point about how women have to try to not be too emotional when they explain their symptoms, not be too hysterical, but also don't be too stoic because if you're too stoic and you're trying to be like a man, then you won't be believed. And then if you, if you look too good, then you may, you must not be in pain because you look good, but if you look too disheveled, you're not going to be respected. So it's like, gosh, it's so hard to just go to the doctor as a woman. It is hard to go to the doctor. Well, I mean, so the answer is, you know, I, I, I would think the answer would, you know, how do we correct this? You know, it's almost like when we're reading just medicine, how do you correct this? And I think that it's, you know, you could say it's one person at a time, but that's not good enough, right? I mean, you've got women that aren't being helped and it's not just pain. You know, I mean, I think to the part that Lorena talks about with the heart disease piece and, you know, all of those, you know, in part two, all of those kind of how heart disease presents differently in women and how you can have like this microvascular disease. I mean, I definitely didn't know about that in internal medicine. And, you know, and then when we were just going to the ER with chest pain and you're saying, oh, you just got anxiety. She's like, no, my, my, my, I'm, I'm having a heart attack and they're having heart attacks in the ER and being sent home. I mean. His reflux, go home. Go home. Yeah. You know, my partners tell the story. His wife who was a nurse and came into the ER and was having some weakness and some breathing issues and was told by one of the, you know, dinosaur ER docs that recently was still seeing a patient while you're a nurse, you're, you're under a lot of stress and you need to, she had Guillain-Barre and ended up in an iron lung. Like, you know, a few weeks of the starting. So it, I mean, we know what happens. Gary, I think your point is to do one person at a time. That's tough. I think a good way to try to address this would be to have, rather than having women up there speaking about, you know, what they do in their practice or the symposium we had last time, have something addressing specifically this, you know, symposium. But, but one of the issues is, you know, yeah, women do have more anxiety and depression. And yeah, the studies have shown that people with anxiety, depression, their outcomes aren't as predictable as people without. So we need to suppose him, have somebody speak to, okay, then how do we intervene on the anxiety and depression beforehand? It may make it better, or how do we manage them differently? You know, not, not giving them surgery, but do we need to come up with better strategies? We need to be more proactive starting PT post-op or whatever the case might be. Are they the ones that might do better with a little gabapentin after surgery? I don't know, but I think because I can tell you that, I mean, I'll be honest, it's, I'd much prefer seeing a patient with like severe ankle arthritis, you know, that needs their ankle fused or their ankle replaced rather than a patient with, you know, vague foot pain with fibromyalgia. I mean, I see those patients. I see a lot of those patients. I see a lot of CRPS patients and yeah, the majority of them are women. And do I prefer the chip shots? You know, the straightforward ones where I go in there, I do the operation to make the patient better, of course. So, but I think part of it's, it's because we don't get as good results that if we can somehow, somebody that's really good at it, you know, set up a symposium and talk about what, how do we approach the patient? What's the best way to approach a patient with anxiety depression? What is the, you know, the patient with CRPS, what's the current recommendation for, you know, sympathetic blocks and ketamine infusions and all that, so that this doesn't seem like such a problem. And I have lots of patients with fibromyalgia. I tell them, well, you know, your problem, it's a pain magnifier. So, if we operate on you, you're going to hurt more, but we can do surgery. I mean, I never turned a patient like that down, but I don't think I necessarily have the answers. But if somebody could give us strategies for, you know, what do you do with the patient that's got anxiety and depression, but they've got a real problem and you've got to fix it. They got the bunion. We know they're going to hurt more afterwards, but what can we do besides our usual, you know, having a cut on it and well, you're going to have more pain. What can we do that might make it better? If we had a symposium on that, A, get a lot of those of us who treat these patients better, you know, knowledge base, and B, maybe could talk to the overwhelmingly white male majority of our society even, you know, orthopedic surgeons in general, but our society that don't want to treat these patients. I think if you showed them that, yeah, you can treat them, you can have successful results. I bet that'd make a huge difference. So, if we could do something like that, focusing, you know, on these sorts of problems, you know, CRIPS, fibromyalgia, I mean, all these different things, you know, how they interact with our surgical patients and their outcomes and strategies for giving them better surgical outcomes, not to not operate on them, but how can we maximize our outcomes? And I, again, I'm not the expert on that. Maybe get a pain management doctor to come in or anybody in our society with expertise in this. I bet that'd make a huge difference because again, it wouldn't just give us more knowledge, but it'd also decrease the bias if the people in the audience says, oh Christ, I don't want to hear about fibromyalgia. Wait a second, you give a patient this, or you can do that, and they're going to do better. I bet that'd make a big difference. So, Dave, I see a great paper coming to FAI on that, but in reality, the reason why we don't have the answers for that is because nobody's studying it. And that was another thing that was pointed out so clearly in the book is that the funding for these predominantly female diseases that we don't have a great understanding of really lack any support from the NIH or anything else. So I totally agree. We need education around it. But the problem is, is that even the experts don't know. And I can tell you that even in anxiety and depression, the treatment is so poor and the disease, both of those diseases, in my opinion, are so poorly understood by the medical community. I don't even know. I'm not sure anyone can tell us how to best treat them. What would be interesting to see is if we had a cohort of patients that we could look back on and see if anything we did worked. But if there is some expert out in the world, that would be great. The other thing to consider is maybe somebody from this committee or to approach the research committee and say, hey, why don't we designate, you know, a certain seed grant, you know, funding for, you know, outcomes of surgery and the differential outcome of surgery and orthopedic foot and neck surgery and women versus men or something along those lines. And you probably get a company that is specifically like Stryker, hit them up for that and say, yeah, we'll gladly fund a $25,000 initiative for, you know, outcome of women's foot and ankle surgery. And you can have specific things. Bunion is not a good choice, I don't think, because vast majority of that's in women. But look at, you know, ankle arthritis surgery in women and men and their outcomes and differences in treatment. But I think that we could probably get funding, but that would be, if there's money available, it's going to start getting attention, because first of all, we'll learn about it. And those of us that do research that are interested in getting funding are going to be applying for those grants. I mean, that'd be one thing to do is maybe make a suggestion to the research committee to that effect. That's well taken. That's very well taken. Because that's exactly in terms of, you know, when they went over the autoimmune part, and that was the part that I thought was really interesting that they said that, you know, I think three-fourths of those cases are women. And if it were men, would we have all these gaps? And to me, I would say that is like a resounding no. Like, I mean, I just know, you know, when you think of there's drugs like, you know, Cialis and stuff out there that really don't have any real measure of use, but they're out there and make money. But then things like autoimmune diseases and then people have multiple ones of those. And that is something that definitely hits home for foot and ankle in terms of rheumatoid arthritis. How are rheumatoid arthritis patients doing? How are our patients with lupus doing? And those are predominantly women as well. We don't really look at them. And I know some people that don't really, I mean, for a while until we really had those biologics, I mean, four foot rheumatoid surgery was brutal. I mean, you're getting metatarsal head resections and a first MTP fusion. I mean, who wants that? You have to really be doing poorly. And so now we have those biologics and some of the research has shown that we can do some of our joint sparing procedures, but that wasn't orthopedic surgery led. And as you just continue to come around in this book for women, and then they had kind of some intersectionality. You had a black woman professor that has lupus, that has chest pain, who if you know anything about lupus and you're in the ER, that pericarditis is a complication and she's getting that. And until she says that she's a PhD, she's not getting any help for it. And so she's a woman and then she's black, but as a PhD and is able to get help. But what about the person that doesn't have a PhD? And I just think that those are some of the things that David, as you say, would be things for research. But once Holly publishes that paper, I'll know that I should send all my lupus patients to HSS. I mean, there's kind of a fear a little bit when you publish some of these papers that now that you're the expert in it, and then we're all like, well, you know what? You just got to catch the plane. And so I think that is something, the stigma of some of these things too. It's kind of like when you have a procedure that you're learning how to do and you're anxious that first 10 or so, and then you kind of have your learning curve. And then when it's on that day, maybe you don't even really stress it the night before. I think some of that's what happens when we have these autoimmune diseases, because we don't know anything about them. You don't have, I think they said an autoimmunologist in the chapter. I think that would be very helpful because as I said earlier, you send someone with an arthritis panel and their anti-CCP is one below what it's supposed to be. They're like, oh, you don't have rheumatoid arthritis. Like they have something, their CRP is high. They have something. Well, no, we're going to give them some naproxen and maybe some methotrexate. Methotrexate, I mean, I wouldn't want to be on that at all. So we just don't, we don't have, you know, folks that are really looking into these things and looking into women's health. And although we have a tremendous number of women going into medical school now, it's not being taught in that fashion. It's kind of like, you know, there's like this awakening for me when I started reading about some of the inequities and the treatment of people of color. And then now all of a sudden I'm learning that, you know, our population of women aren't being looked at either. It's like, what are we even teaching? So the people going into medical school that are 50% women are learning medicine the same way that men have been learning it and been taught. So then that is just coming around again, more and more. And so that's kind of where, David, I think I agree with you, more research needs to be done, but I just, I don't really see it changing anytime soon. I guess I'm, you know, the downer here, but I just don't see where, if you're not really being active, you know, and, you know, we're talking about it and we all read the book, but there's, you know, 20 of us on here tonight. So it's just kind of like, how do you get that information out there so that we can take care of women properly? I just kind of wanted to pose that. Symposium, we have hundreds of people in the audience at the AOFS meeting, main session. That's how you do it. I would suggest, I mean, we probably already have the agenda set for this meeting, but maybe we could do it in the winter meeting or something like that. If you do a webinar or something like that, it's variable, but if you have people, the captive audience at a given meeting, you'll have attendance at it. Yeah, and you know, it's incremental. I mean, just as long as the Supreme Court doesn't get involved in decision-making, I think we can make some progress, but I digress. Yeah, we're all heads will explode. If you think about that, continue to. I mean, that's, I mean, it's believable because it happened, but I just, I mean, so in addition to, I think that's a great idea to try to figure out a way to have a symposium on that, maybe that'll get some things started. I also think on a broader scale, trying to have medical schools. I mean, this is what she talks about in the book and almost like how in our last book, we were saying we need to teach the people who are coming in about that and have them be receptive. I mean, we've all sat in places where you have people that you're trying to teach it and they maybe aren't, they're not interested in it or what have you. They just want to learn what makes money. And I guess this could, if you really were to approach it as a women's health specialist, but I just don't have the answer for it. I think the symposium is great. One of the other biases that was mentioned in conjunction with gender was obesity. And I think that that's, I see it in myself as a major issue, but when an obese patient's pain is often dismissed as well, oh, lose weight and your knee pain will go away, lose weight and your cough will get better, lose weight and your everything will get better. And to a certain extent, I do think that weight contributes to a lot of issues that cause pain, whether it's osteoarthritis or even foot pain. I think that obesity in a lot of ways does contribute to foot pain, but I still think it's, we have to make an effort not to dismiss people or dismiss real diagnoses as just being, oh, if you lose weight, your pain will go away. And in particular, heavy women, you know, the author mentioned a couple of instances where basically heavy women are so-called fat shamed for being slightly overweight, where a male of the equivalent BMI or even five points higher may not in any way have his BMI addressed or have his obesity addressed. So it seems like in some ways, obese women are more targeted as being responsible for their own symptoms as compared to normal weight women and even obese men. That was something I had never really thought about or contemplated. I agree with you. You know, you look at that over the last couple of years when you have, let's say like artists like Lizzo who are proud of how their normal bodies are and you kind of watch the performance and those women are definitely in shape. And so there is definitely, I've stopped, I haven't stopped addressing weight, but I've tried to make it a point, especially as I try to become more conscious of people's normal bodies and how they should be proud of who they are and in their bodies. And I don't know if they're healthy or not. I know some skinny people that have tremendous cardiovascular issues to really try to make sure I'm not using that as a crutch to get out of the room because I can go see somebody else. Like, hey, you know, lose 30 pounds because if your foot hurts and your ankle hurts, how are you supposed to lose 30 pounds before I do some surgery on you? And so that's kind of, you know, when they mentioned that and how, you know, you go to the doctor, I guess there was a woman that had asthma or something and he just kept saying, you know, you got to lose weight. Well, how are you supposed to do that? And this may be my natural weight. And can you please help me? I mean, part of the thing that as physicians, when people, as I'm also honored when people come see you, when they say they've heard of you and they're coming to see you, like that's someone asking you for help. And that's, they're doing that every day. And then when you kind of just say, oh, you know, you come in with your, you know, your white coat on, we're looking, just came from the gym, looking a little slim. And then the first thing you say, well, you need to lose weight, just kind of feels like you're letting them down. And then this book kind of further reinforces how that happens for women. And, you know, as men, you know, you get that executive cut suit, really can't tell. And so I think that just, again, we're not listening to women. I do like the idea of a symposium, but I just think in general, getting the idea across that we need to listen to women, which, you know, I don't think socially, you know, we're not socialized to do that. I think that it just takes, it shouldn't take that much, but it seems to. The other point is that, and dig in a little bit in a chapter that talks about heart disease. I thought what's very interesting, how she pointed that early in the nineties, the first like meeting to gather women to talk about heart disease, it was focused on how they can take care of their husbands with high risk factors for heart disease, like not to talk about them, but how they can intervene to take care of their husbands. And like, there were like no meetings about how you can take care of yourself until like 2000s. And I think we're like, we're so used to these, that she also talked how women many times having symptoms that can be related to any cardiac disease or COPD that can be life-threatening, they avoid to go to seek care because they're so afraid that they will be titled as like, oh, you have issues or you have this, and they just don't wanna waste their time, their effort and their energy. So I think that's something that we also need to a society to intervene. We need to encourage people to hear their bodies, their symptoms, and hey, it's okay if your symptoms are different than the ones that traditionally we have, going as they're like the red flags. It's okay if you feel like you are having a life-threatening condition, go there and look for care. Because there's the other part, like we can encourage people to be looking at these, but then these, we are the women, we are not looking for care. We are so afraid that we won't have the proper care and we don't wanna feel frustrated about it, that we're just not going. And I think that's also something that we need to think how we can work on it and just tell them to speak up for themselves. Yeah, I definitely agree with that. And I mean, even listening to them and they shouldn't have to have their husband or their son or their grandfather there with them so that they can be heard. It's definitely lack of listening. And I feel like I'm a pretty good listener, but I'm not perfect in that way. I'm not perfect, I'm definitely human and I will definitely listen more. I'm gonna try and ignore the people with the fibromyalgia or the other diseases and truly listen to their pathology after reading this because of what I've learned from this book. So even though I thought I was a good listener, I don't think I am. And this definitely has brought some eye-opening ways for me to improve, which I think is critical. And then for us to be responsible to pass that on to our trainees, the medical students that are with us so that they can see what you're doing. And maybe they're not recognizing it and maybe we need to make it a point that, look, I saw this, but I ignored it. I tell patients all the time, hey, what brought you in? And they always say, well, why didn't you look at the chart? And I was like, well, you know what? I don't wanna get jaded by what I've seen in that chart. I wanna hear it straight from you. So you share with me why you're here in my clinic and how can I help you? And take the time to teach those aspects so that that continues on and we're not just one person but trying to teach those below us. Thank you. I think that the hysteria kind of carve out and the use of hysteria as a wastebasket and how she kind of wove the tail of how when women would have problems or health problems, it was just, oh, it's hysteria. Again, we're focusing on women's reproductive parts. And then slowly as science has moved on or our knowledge base increases, we slowly carve things out. Oh, it wasn't hysteria, it's a teratoma. Oh, it wasn't hysteria, there's MS. Oh, it wasn't. And I just think that just early on, the vapors, oh, women are fainting. And then it turns out that there's really a medical reason behind it. I think part of it is to keep people being kind of inquisitive about things. I had a student and a resident with me the other day and I was surprised both were women and they did use that term hysteria. And I happened to be reading this book and we were gonna go over this book. And I just was kind of, that was my point that when we bring people through the medical education, we just keep telling them the same things, whether it's males or females, we just keep teaching them the same thing. Just like when something like black people don't feel pain can go on from slavery, almost 150, 200 years ago, we're still letting these things happen. And we're still letting to what Holly said before we got on about bunions at the beginning of every bunion chapter or review paper, it just talks about shoe wear, women's high heels and are causing the bunions. And just, I think that we're gonna have to start looking at how we're educating those that come behind us. And I definitely think that can be a symposium. I do believe that certain articles and book chapters and oversight can help, but there's, it'll be the next Twitter thing where, I think it was the vascular surgeons with women wearing baby bathing suits, not looking professional. It's just a whole kind of thought process that will have to change. And I just, I'm not seeing where that's gonna change at all. I just think that it'll be the same small percentage of people kind of shouting into the wind. And maybe I'm, again, being the downer, but does anybody have more of an optimistic view of this than I do? No, until we start teaching people a little bit better ourselves, but it's all about sort of blaming a woman, right? It's you have this problem in your foot because you wore bad shoes, it's your fault. You have this pain because you're obese, it's your fault. And it's this sense that if you're a man and you have erectile dysfunction, it's not your fault. It's not your brain, it's not your fault. We have a pill for you. You take this pill, it's a bodily issue. But if you're a woman with vulvodynia, I hate to even say that word, but that was brought up in this book, it's your fault. You have mental issues, you have to sort out your own life before you're allowed to enjoy any intimate interactions. And it just sort of all goes back to this. To me, it's very much of a blame game and sort of taking, you sort of take control away by blaming the woman. And we're seeing that pan out with recent Supreme Court decisions and we see it in our own practices every single day. And I think that maybe David's right that we need to have a symposium on this, but I'm not really sure. The fact that we only have 17 people on this call makes me think that there may not, that people may sneak out to lunch if we have it even as a symposium at the AOFAF. Yeah, I think part of this, just tying this back a little bit with history too is, I don't know about everyone else, but I just learned recently that the witches in Europe in the 1500s and part of the Salem witch trial were like medicine women. They were midwives and healers. I don't remember learning that back when I was in middle school or whatever. And so when all of those women were killed throughout Europe and in the US, I think a lot of that knowledge didn't get passed down because they were teaching women about their bodies and about their reproductive system. And then medicine then became more patriarchal. And so I think we lost a lot of good knowledge there potentially. Yeah, I think even in terms of how to change things, I think it's gonna take a long time, but I think even just starting in the med schools with the acknowledgement that there are differences between men and women, and that we don't even know what they are, but in each area, like in rheumatology. And I remember, of course, learning the difference in how a heart attack can present in a male versus a female. But beyond that, I don't remember learning much else besides the reproductive stuff, of course. But yeah, I think at least just pointing it out as, okay, there are differences, and this is an area that we really need to research and investigate further is a start. I still think the symposium is a way to go. I don't think anybody's saying it's not. I mean, I think that I mean, I would certainly agree. It's it's disappointing to see the number of people on this. But then again, you know, this is a it's an evening, you know, I turned my camera off shortly to eat dinner in the other room, but I was listening to every word that was said. I mean, so, you know, people have to make conscious decision to make the time to be here and to read the book. But if you have a symposium where you're just, you know, where people are at the meeting anyhow and you don't stick it to the very last day or first thing in the morning, a sandwich in the middle, I think people listen. And I think that's the only way we're going to make a big have any significant impact is my guess. I think that we I think do we we're going to have to make. Make sure that we women's health and in terms of financial space as well is something that we focus on as I think having our speaker being a woman, and I certainly hope that she addresses some of these things. And as we have our discussion with her, I believe that we need to make sure that we address that as part of our DEI symposium, because, you know, like you said, maybe it's because it's June, but I don't think so. I think that maybe when you're in medical school and they say there's going to be a woman's health kind of symposium and I won't say symposium, but I do remember that I went to what was formerly Women's Medical College, MCP Hanuman. So there was a they would make a point of that being part of our curriculum and you could see the trickle of guys that would just, you know, decide to have lunch, decide to have to go to the gym and, you know, really kind of making this a focus, making it a testable item is going to be something that makes people really kind of perk up because everybody wants to do well on the test and learn about it. And so making it a true learning objective in medical school, I think is really the only way that any of this is going to happen. If it's something that's optional, then you just get the people that are kind of interested in being better people or just have some time. But in order to really reach people broadly, I think it will have to be a learning objective. Now, I'm not on any medical school curriculum. I don't have a determining factor, but I think us as physicians that are practicing physicians will have to be the ones that say, hey, this is what I've learned and especially men. I mean, just like, you know, for the things that are people of color, there's nothing like having a white person and especially a white man say something about the rights of people of color. And so I think as a man and even as a person of color that's a man, there is a certain from being being a male that allows me to enter spaces and have a voice that women are able to have. It's important for us to really push this forward because there's so much in this book that would, you know, just makes me feel like a bad doctor and a bad doctor for the last 20 years. So in order to do that, I think that's really the only way. And the symposium is part of that, but I am disheartened that I mean, to all the people that called in, thank you. But I am disheartened that such a such a very important topic. We don't really have the discussion from our members that I was anticipating and hoping for. I imagine that that's maybe got people on this call down, but also, you know, if this had happened six months ago or 12 months ago, I think for, you know, we're probably not going to get into it 1010, but a lot of people feel like we we've taken some giant steps backwards in terms of women's rights, women's power, women's consideration, certainly from a health perspective. And so, you know, this is a lot of the stuff we've talked about tonight is about power. And and, you know, Ali mentioned a lot of it, but, you know, deciding deciding why you are a certain way and what your options are to to handle it. And, you know, it's hard it's hard to see much of a light of a tunnel in the last several days. As a father of three daughters, it's been a tough week. You know that it has no and I think you made a great point in that, you know, it men have to advocate that this is important, because otherwise I think it's just going to be viewed as women. Just being women and, you know, complaining and trying, but, you know, that's that's what we need to buy in, like you said, for, you know, people of color, you know, white males saying that this is important speaks volumes, you know, a male of any color talking about, you know, women's health is important, I think speaks a lot. And, you know, if if this symposium happens, it might be something that we consider, you know, it's all men who are presenting this topic and not have any women up there to support the the importance of it. That's a great idea. That's a great idea. I mean, it's definitely when you look at this book, you hear that whenever women open their mouths, it's just seeming like it's complaining all of a sudden, like it's not a reason why you have pain. And, you know, when we look at our what's the chief complaint? So we are asking people to complain. Tell us what your complaint is. And then when they they tell us now we're mad, now we're frustrated. Now we don't want to listen. And I think those are the those are the things that when you have an impressionable medical student, when you're just getting into it, I mean, a lot of us are probably, you know, we've been in for a while. We probably set in our ways to a degree. But when you have an impressive medical student or someone that's even premed and making these things, learning objectives, even if you don't want to learn it, you end up learning it. I mean, there you know, I didn't like. I wasn't a real big fan of rheumatology at all, and it's partly because I just felt like everything was methotrexate and they couldn't really fix anything. Neurology is like that for me, too. I'm just like, what are you doing? But, you know, you do learn and pick up things. And, you know, it just so happens that you read a book like this and you realize how structurally it's put into place for you not to learn when there's not even research into something. I mean, how are you going to figure it out? It's not even seeming like it's a thing of interest, which is just crazy, it seems. Yeah. Are there any? No, it sounds like we're winding down. I just want to give a moment if anybody has any last comments. I think this has been an excellent discussion and one that I have four more minutes though. We've got four more minutes for CME. That's why I keep running my mouth. Three minutes. I'll take one of those minutes. This is important. And, you know, I'm happy to be your TWG, your token white guy, if you want. I mean, I don't have expertise in these things, you know, with regard to the. Women's issues like this, like these diseases, I certainly see a boatload of them, but I could certainly serve as a moderator if we had a symposium or something like that. But I could certainly serve as a moderator if we had a symposium or something like that. And, you know, both Mike Gerner, who's on the call, he hasn't said anything yet because he's I don't see his picture. But anyhow, the two of us are in the presidential line and the board is very interested in this. And this is not something that, you know, it's like, oh, that's right. We've got to do this. I'm on my departmental committee also. So there's Mike and Mike can chime in, too, because he's further along the presidential line than I am. But it's important to the board and we want to help with these things. So if any of you have ideas, let either one of us know, because we'd certainly be more than receptive to hearing about it. Mike, you want to chime in? Yeah, I mean, I think it's one of those things that has to be like a multipronged, repetitive approach, you know, it's not just one symposium or one seminar. It's like, you know, multiple lectures, multiple times. So people get exposed to different ways and it gets reinforced. So and, you know, with respect to who gives it, I think it needs to be given by both men and women. I think if it's just men, some people are going to say, well, that's just men's view on this thing. We need a woman's perspective, too. I think it's good to get both people's perspective on it. Or both sexes perspective on it. I had a quick point. I remember there is a book called Just the Female Athlete or the Female ACL. And there's so much work on ACL about how small the condyles are, what is the thickness of ACL. And I could see some book down the road, just the female foot and ankle or something like that. I don't think there is one. Probably I'm unaware, but I think that could be one thing where the female foot and the female ACL is well established. And there are several books on that. So something on those lines would be better, sort of giving more information for everybody. Maybe that's the name of the symposia. You know, do a whole symposia on that. That'd be pretty cool, I think. Yeah, the only danger is the minute you put the female anything as the title, as a title of a whole section, you may lose 90 percent of the audience. So I like Dave's idea of like sandwiching it in and like one maybe larger topic with multiple speakers in the middle of a lot in the middle of the program. I think that's a better way to get to get people to listen. I like your idea, Caitlin, but I'm just thinking realistically about. No, I totally agree. I definitely didn't mean that's like, you know, one thing that everyone's coming to. I think sandwiching it is definitely the way to go. I'd be very interested in that. I mean, I mean, everything I say in terms of it needing to be something that is a learning objective and at the root of something that for our society. So as the role of DEI in this, I think it plays a significant role and that should be something that we work on. I also think like what we were talking before, can I like maybe make in a way that we can just put more attention to just kind of designate a specific funding for research in like in this case, females. But also I feel sometimes in some minorities where we find more prevalence of certain diseases that we can explore more out of what is going on and what are the difference between then and typical sort of type of people that we have included in our studies. So we all can learn what we should be looking at, because sometimes we just look at the typical things and they just present in a different way. So really looking at that as well, I think we can make an impact. Any other final comments? I think Gary had asked me to talk about a couple of papers, if there was anything about foot and ankle. So there were a couple, I think one was from Judy Baumhauer in JPJS, a long time ago in 2013, about what the PROs for female and male should be different. According to her, female think there is different issues for them in that same foot, while a man might think that it's a different issue for them. So I think she came out with the idea of PRO different for each male and female. Probably that's kind of a very attractive option, I thought. I think the other thing was, I think Dr. Thorderson is here, I think there was one article saying, which of the high impact journals are talking specifically about foot and ankle related issues? And FEI came on top that they have been consistently promoting that. So that's another article I came across that, you know, and so just to compare in relation to the other journals. So FEI has been in the forefront and I think they have consistently published papers related to sex-derived issues in foot and ankle. And I had one more study in regards to it from the Korean Journal about Bunyan and how they talk about how, you know, the female first metatarsal is more conical, more circular. And so they talk about more high chance of recurrence. And so more of these articles, and I can send it across later on, but more of these articles will make everybody aware of the issues. Thank you. Thank you for that. Thank you very much. I want to remind everybody who's attended tonight, don't forget to claim your CME. They will send out an email and definitely go to the course and evaluation, which Jennifer has put in our chat box. A reminder, October 12th is our next on the same page. So please tune in. And as soon as we, as a committee and work with RJOS on deciding the book and or articles or just articles, we haven't figured that out yet. We will definitely send out that information to all of you and to the rest of the society. So thank you, everybody, for a wonderful discussion. Yes. And we'll keep chugging along. That's right. OK, bye bye. See ya, everyone. Good night, everyone. Thank you. Thank you. Bye.

Maya Doonesbury

Doing Harm

gender biases

healthcare

knowledge gaps

medical education

bikini medicine

women's health

symptoms

education

gender equality