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, Volume 36, Issue 3, pp 501–508 | Cite as

Clinical Decision-Making, Gender Bias, Virtue Epistemology, and Quality Healthcare

  • James A. MarcumEmail author
Article

Abstract

Robust clinical decision-making depends on valid reasoning and sound judgment and is essential for delivering quality healthcare. It is often susceptible, however, to a clinician’s biases such as towards a patient’s age, gender, race, or socioeconomic status. Gender bias in particular has a deleterious impact, which frequently results in cognitive myopia so that a clinician is unable to make an accurate diagnosis because of a patient’s gender—especially for female patients. Virtue epistemology provides a means for confronting gender bias in clinical decision-making and for correcting or even preventing its impact. The medical literature on cardiovascular and coronary heart disease is used to illustrate the role intellectual virtues can play in redressing the deleterious impact of gender bias on clinical decision-making and practice. Finally, questions are considered surrounding the pedagogy of intellectual virtues for medical students and practicing clinicians in order to provide quality care for patients, regardless of gender.

Keywords

Cardiovascular disease Clinical decision-making Gender bias Intellectual virtues Quality healthcare Virtue epistemology 

References

  1. Adams A, Buckingham CD, Lindenmeyer A et al (2008) The influence of patient and doctor gender on diagnosing coronary heart disease. Sociol Health Illn 30:1–18CrossRefGoogle Scholar
  2. Albert DA, Munson R, Resnik MD (1988) Reasoning in medicine: an introduction to clinical inference. The Johns Hopkins University Press, BaltimoreGoogle Scholar
  3. American Heart Association (2015) Cardiovascular disease: women’s no. 1 health threat. https://www.heart.org/idc/groups/heart-public/@wcm/@adv/documents/downloadable/ucm_472728.pdf
  4. Anderson A (2012) Epistemic justice as a virtue of social institutions. Soc Epistemol 26:163–173CrossRefGoogle Scholar
  5. Anspach RR (2010) Gender and health care. In: Bird CE, Conrad P, Fremont AM, Timmermans S (eds) Handbook of medical sociology, 6th edn. Vanderbilt University Press, NashvilleGoogle Scholar
  6. Baehr J (2011) The inquiring mind: on intellectual virtues and virtue epistemology. Oxford University Press, New YorkCrossRefGoogle Scholar
  7. Battaly H (2008) Virtue epistemology. Phil Comp 3:639–663CrossRefGoogle Scholar
  8. Baumhäkel M, Müller U, Böhm M (2009) Influence of gender of physicians and patients on guideline-recommended treatment of chronic heart failure in a cross-sectional study. Eur J Heart Fail 11:299–303CrossRefGoogle Scholar
  9. Bird CE, Rieker PP (2008) Gender and health: the effects of constrained choices and social policies. Cambridge University Press, New YorkCrossRefGoogle Scholar
  10. Bönte M, von dem Knesebeck O, Siegrist J et al (2008) Women and men with coronary heart disease in three countries: are they treated differently? Womens Health Issues 18:191–198CrossRefGoogle Scholar
  11. Canto JG, Goldberg RJ, Hand MM et al (2007) Symptom presentation of women with acute coronary syndromes: myth vs reality. Arch Intern Med 167:2405–2413CrossRefGoogle Scholar
  12. Carel H, Kidd IJ (2014) Epistemic injustice in healthcare: a philosophical analysis. Med Health Care Philos 17:529–540CrossRefGoogle Scholar
  13. Celik H, Lagro-Janssen TA, Widdershoven GG et al (2011) Bringing gender sensitivity into healthcare practice: a systematic review. Patient Educ Couns 84:143–149CrossRefGoogle Scholar
  14. Chilet-Rosell E (2014) Gender bias in clinical research, pharmaceutical marketing, and the prescription of drugs. Glob Health Action 7:25484. doi: 10.3402/gha.v7.25484 CrossRefGoogle Scholar
  15. Colbert JD, Martin BJ, Haykowsky MJ et al (2015) Cardiac rehabilitation referral, attendance and mortality in women. Eur J Prev Cardiol 22:979–986CrossRefGoogle Scholar
  16. Croskerry P (2000) The cognitive imperative: thinking about how we think. Acad Emerg Med 7:1223–1231CrossRefGoogle Scholar
  17. Croskerry P (2002) Achieving quality in clinical decision making: cognitive strategies and detection of bias. Acad Emerg Med 9:1184–1204CrossRefGoogle Scholar
  18. Croskerry P (2005) The theory and practice of clinical decision-making. Can J Anesth 52:R1–R8CrossRefGoogle Scholar
  19. Croskerry P (2009) Clinical cognition and diagnostic error: applications of a dual process model of reasoning. Adv Health Sci Educ 14:27–35CrossRefGoogle Scholar
  20. Dentzer S (2011) Still crossing the quality chasm—or suspended over it? Health Aff (Millwood) 30:554–555CrossRefGoogle Scholar
  21. Dielissen PW, Bottema Verdonk P et al (2009) Incorporating and evaluating an integrated gender specific medicine curriculum: a survey study of Dutch GP training. BCM Med Educ 9:58. doi: 10.1186/1472-6920-9-58 CrossRefGoogle Scholar
  22. Dijkstra AF, Verdonk P, Lagro-Janssen AL (2008) Gender bias in medical textbooks: examples from coronary heart disease, depression, alcohol abuse and pharmacology. Med Educ 42:1021–1028CrossRefGoogle Scholar
  23. Downie RS, Macnaughton J (2000) Clinical judgment: evidence in practice. Oxford University Press, New YorkGoogle Scholar
  24. Doyal L (2000) Gender equity in health: debates and dilemmas. Soc Sci Med 51:931–939CrossRefGoogle Scholar
  25. Elstein AS (1999) Heuristics and biases: selected errors in clinical reasoning. Acad Med 74:791–794CrossRefGoogle Scholar
  26. Fricker M (2007) Epistemic injustice: power and the ethics of knowing. Oxford University Press, New YorkCrossRefGoogle Scholar
  27. Gambrill E (2005) Critical thinking in clinical practice: improving the quality of judgments and decisions, 2nd edn. Wiley, HobokenGoogle Scholar
  28. Garb HN (1997) Race bias, social class bias, and gender bias in clinical judgment. Clin Psychol Sci Pr 4:99–120CrossRefGoogle Scholar
  29. Goldman AI (2012) Reliabilism and contemporary epistemology: essays. Oxford University Press, New YorkCrossRefGoogle Scholar
  30. Graber ML, Kissam S, Payne VL et al (2012) Cognitive intervention to reduce diagnostic error: a narrative review. BMJ Qual Saf 21:535–557CrossRefGoogle Scholar
  31. Groopman J (2007) How doctors think. Houghton Mifflin, BostonGoogle Scholar
  32. Gupta M, Upshur R (2012) Critical thinking in medicine: what is it? J Eval Clin Pract 18:938–944CrossRefGoogle Scholar
  33. Hamberg K (2008) Gender bias in medicine. Womens Health 4:237–243Google Scholar
  34. Hammarström A, Johansson K, Annandale E et al (2014) Central gender theoretical concepts in health research: the state of the art. J Epidemiol Community Health 68:185–190CrossRefGoogle Scholar
  35. Healy J (2011) Improving health care safety and quality: reluctant regulators. Ashgate, BurlingtonGoogle Scholar
  36. Henrich JB (2004) Women’s health education initiatives: why have they stalled? Acad Med 79:283–288CrossRefGoogle Scholar
  37. Hicks EP, Kluemper GT (2011) Heuristic reasoning and cognitive biases: are they hindrances to judgments and decision making in orthodontics? Am J Orthod Dentofacial Orthop 139:297–304CrossRefGoogle Scholar
  38. Hochleitner M, Nachtschatt U, Siller H (2013) How do we get gender medicine into medical education? Health Care Women Int 34:3–13CrossRefGoogle Scholar
  39. Howes M (2012) Managing salience: the importance of intellectual virtue in analysis of biased scientific reasoning. Hypatia 27:736–754CrossRefGoogle Scholar
  40. Institute of Medicine (2001) Crossing the quality chasm: a new health system for the 21st century. National Academies Press, Washington, DCGoogle Scholar
  41. Kassirer JP, Kopelman RI (1991) Learning clinical reasoning. Williams and Wilkins, BaltimoreGoogle Scholar
  42. Kochanek KD, Xu J, Murphy SL et al (2011) Deaths: final data for 2009. Natl Vital Stat Rep 60:1–116Google Scholar
  43. Legato MJ (ed) (2010) Principles of gender-specific medicine. Academic Press, LondonGoogle Scholar
  44. Lipworth W, Kerridge I, Little M et al (2012) Meaning and value in medical school curricula. J Eval Clin Pract 18:1027–1035CrossRefGoogle Scholar
  45. Lloyd-Jones D, Adams RJ, Brown TM et al (2010) Heart disease and stroke statistics—2010 update: a report from the American Heart Association. Circulation 121:e46–e215Google Scholar
  46. Marcum JA (2012) The virtuous physician: the role of virtue in medicine. Springer, New YorkCrossRefGoogle Scholar
  47. Marcus-Newhall A, Thompson S, Thomas C (2001) Examining a gender stereotype: menopausal women. J Appl Soc Psychol 31:698–719CrossRefGoogle Scholar
  48. Martin R, Johnsen EL, Bunde J et al (2005) Gender differences in patients’ attributions for myocardial infarction: implications for adaptive health behaviors. Int J Behav Med 12:39–45CrossRefGoogle Scholar
  49. Medina J (2012) The epistemology of resistance: gender and racial oppression, epistemic injustice, and the social imagination. Oxford University Press, New YorkGoogle Scholar
  50. Melloni C, Berger JS, Wang TY et al (2010) Representation of women in randomized clinical trials of cardiovascular prevention. Circ Cardiovasc Qual Outcomes 3:135–142CrossRefGoogle Scholar
  51. Mikhail GW (2005) Coronary heart disease in women. BMJ 331:467–468CrossRefGoogle Scholar
  52. Möller-Leimkühler AM (2007) Gender differences in cardiovascular disease and comorbid depression. Dialogues Clin Neurosci 9:71–83Google Scholar
  53. Montgomery K (2006) How doctors think: clinical judgment and the practice of medicine. Oxford University Press, New YorkGoogle Scholar
  54. Moore SHE (2008) Gender and the ‘new paradigm’ of health. Sociol Compass 2:268–280CrossRefGoogle Scholar
  55. Mosca L, Banka CL, Benjamin EJ et al (2007) Evidence-based guidelines for cardiovascular disease prevention in women: 2007 update. J Am Coll Cardiol 49:1230–1250CrossRefGoogle Scholar
  56. Mosca L, Benjamin EJ, Berra K et al (2011) Effectiveness-based guidelines for the prevention of cardiovascular disease in women—2011 update: a guideline from the American Heart Association. J Am Coll Cardiol 57:1404–1423CrossRefGoogle Scholar
  57. Mozaffarian D, Benjamin EJ, Go AS et al (2015) Heart disease and stroke statistics—2015 update: a report from the American Heart Association. Circulation 131:e29–e32CrossRefGoogle Scholar
  58. Napier S (2011) Virtue epistemology: motivation and knowledge. Continuum, LondonGoogle Scholar
  59. Nettleton S (1996) Women and the new paradigm of health and medicine. Crit Soc Pol 16:33–53CrossRefGoogle Scholar
  60. Norman GR, Eva KW (2010) Diagnostic error and clinical reasoning. Med Educ 44:94–100CrossRefGoogle Scholar
  61. Norman G, Sherbino J, Dore K et al (2014) The etiology of diagnostic errors: a controlled trial of system 1 versus system 2 reasoning. Acad Med 89:277–284CrossRefGoogle Scholar
  62. Payne VL, Patel VL (2014) Enhancing medical decision making when caring for the critically ill: the role of cognitive heuristics and biases. In: Patel VL, Kaufman DR, Cohen T (eds) Cognitive informatics in health and biomedicine: case studies on critical care, complexity and errors. Springer, New YorkGoogle Scholar
  63. Pellegrino ED, Thomasma DC (1993) The virtues in medical practice. Oxford University Press, New YorkGoogle Scholar
  64. Pilote L, Dasgupta K, Guru V et al (2007) A comprehensive view of sex-specific issues related to cardiovascular disease. CMAJ 176:S1–S44CrossRefGoogle Scholar
  65. Politi C, Ciarambino T, Franconi F et al (2013) Gender medicine: an up-date. Ital J Med 7:96–106CrossRefGoogle Scholar
  66. Risberg G (2004) “I am solely a professional—neutral and genderless”: on gender bias and gender awareness in the medical profession. Umeå University, UmeåGoogle Scholar
  67. Risberg G, Hamberg K, Johansson EE (2006) Gender perspective in medicine: a vital part of medical scientific rationality. A useful model for comprehending structures and hierarchies within medical science. BMC Med 4:20. doi: 10.1186/1741-7015-4-20 CrossRefGoogle Scholar
  68. Risberg G, Johansson EE, Hamberg K (2009) A theoretical model for analyzing gender bias in medicine. Int J Equity Health 8:28. doi: 10.1186/1475-9276-8-28 CrossRefGoogle Scholar
  69. Risberg G, Johansson EE, Hamberg K (2011) ‘Important… but of low status’: male education leaders’ views on gender in medicine. Med Educ 45:613–624CrossRefGoogle Scholar
  70. Roberts RC, Wood WJ (2007) Intellectual virtues: an essay in regulative epistemology. Oxford University Press, New YorkCrossRefGoogle Scholar
  71. Robertson RM (2001) Women and cardiovascular disease: the risks of misperception and the need for action. Circulation 103:2318–2320CrossRefGoogle Scholar
  72. Ruiz MT, Verbrugge LM (1997) A two way view of gender bias in medicine. J Epidemiol Common Health 51:106–109CrossRefGoogle Scholar
  73. Sahni S, Fonarow GC (2014) Gender bias treads in implantable cardioverter–defibrillator therapy. Curr Cardiovasc Risk Rep 8:1–6CrossRefGoogle Scholar
  74. Schwab AP (2008) Epistemic trust, epistemic responsibility, and medical practice. J Med Philos 33:302–320CrossRefGoogle Scholar
  75. Schwab A (2011) Epistemic humility and medical practice: translating epistemic categories into ethical obligations. J Med Philos 37:28–48CrossRefGoogle Scholar
  76. Scott KW, Jha AK (2014) Putting quality on the global health agenda. N Engl J Med 371:3–5CrossRefGoogle Scholar
  77. Sen G, George A, Östlin P (eds) (2002) Engendering international health: the challenge of equity. MIT Press, CambridgeGoogle Scholar
  78. Simmons A, Falbe J, Vacek J (2011) Coronary artery disease in women: a review and update. Rev Cardiovasc Med 12:e84–e93Google Scholar
  79. Sosa E (1980) The raft and the pyramid: coherence versus foundations in the theory of knowledge. Midwest Stud Philos 5:3–25CrossRefGoogle Scholar
  80. Sosa E (2009) A virtue epistemology: apt belief and reflective knowledge, vol 1. Oxford University Press, New YorkGoogle Scholar
  81. Tsang W, Alter DA, Wijeysundera HC et al (2012) The impact of cardiovascular disease prevalence on women’s enrollment in landmark randomized cardiovascular trials: a systematic review. J Gen Intern Med 27:93–98CrossRefGoogle Scholar
  82. van Wijk CMG, Van Vliet KP, Kolk AM (1996) Gender perspectives and quality of care: towards appropriate and adequate health care for women. Soc Sci Med 43:707–720CrossRefGoogle Scholar
  83. Verdonk P, Benschop YW, de Haes HC et al (2009) From gender bias to gender awareness in medical education. Adv Health Sci Educ Theory Pract 14:135–152CrossRefGoogle Scholar
  84. Walton D (1999) One-sided arguments: a dialectical analysis of bias. SUNY Press, AlbanyGoogle Scholar
  85. Wenger NK (2004) You.ve come a long way baby: cardiovascular health and disease in women: problems and prospects. Circulation 109:558–560CrossRefGoogle Scholar
  86. Wenger NK (2012) Women and coronary heart disease: a century after Herrick: understudied, underdiagnosed, and undertreated. Circulation 126:604–611CrossRefGoogle Scholar
  87. Wong YL (2009) Review paper: gender competencies in the medical curriculum: addressing gender bias in medicine. Asia Pac J Public Health 21:359–376CrossRefGoogle Scholar
  88. World Heart Federation (2012) Women & cardiovascular disease. http://www.world-heart-federation.org/fileadmin/content/PressBackgrounderApril2012WomenCVD.pdf
  89. Xhyheri B, Bugiardini R (2010) Diagnosis and treatment of heart disease: are women different from men? Prog Cardiovasc Dis 53:227–236CrossRefGoogle Scholar
  90. Zagzebski LT (1996) Virtues of the mind: an inquiry into the nature of virtue and the ethical foundations of knowledge. Cambridge University Press, New YorkCrossRefGoogle Scholar
  91. Zusterzeel R, Spatz ES, Curtis JP et al (2015) Cardiac resynchronization therapy in women versus men: observational comparative effectiveness study from the national cardiovascular data registry. Circ Cardiovasc Qual Outcomes 8:S4–S11CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media Dordrecht 2015

Authors and Affiliations

  1. 1.Department of PhilosophyBaylor UniversityWacoUSA

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