They Just Don't UNDERSTAND

By Anastasia Toufexis

FOR MANY WOMEN, SEEING A GYNEcologist easily outranks visiting the dentist as their least favorite doctor's appointment. A dentist sometimes dispenses pain; a gynecologist too often delivers humiliation. Not only must women lie submissively in stirrups; they frequently must also endure the abasing attitudes of their doctors -- 80% of whom are men. Only the most radical feminists so far have suggested that women doctors alone should be treating women patients. Now, in a heretical stance sure to outrage the medical profession, a male gynecologist is propounding that view. "Men have no business being gynecologists," declares Dr. John Smith. "The role properly belongs to women. They are the only sex truly able to understand, empathize with and appropriately relate to women in the already difficult doctor-patient relationship."

That is just one of the grenades Smith lobs in his new book, Women and Doctors: A Physician's Explosive Account of Women's Medical Treatment -- and Mistreatment -- in America Today (Atlantic Monthly Press; $20.95). Male domination of the medical profession has bred a host of abuses, says Smith, 49, a medical maverick who upset colleagues by starting the first HMO in Colorado Springs, Colo., and now acts as a consultant on national health policy. Research on heart disease and cancer, as well as on the benefits of various therapies, has centered almost exclusively on men. "We've got a body of knowledge that doesn't apply to women," laments Smith. More than 600,000 hysterectomies are performed in the U.S. each year, half of them unjustified, in Smith's opinion. "That's over $1 billion in physician fees alone," notes Smith, who contends that doctors are overpaid and undersupervised. "No wonder they don't have a lot of motivation to develop alternative treatments to the excuses used for hysterectomies."

Sexism, ranging from outright abuse to subtle debasement, is pervasive in the profession. Smith recalls a colleague who invited him to do an exam on a patient under the false guise of a consultation because "she has a body you won't believe." Another physician, whenever faced with an "emotional" female patient, would draw in his notes a stick figure with a lightning bolt going into its head and write down a nonsensical diagnosis of "zigzybiasis," signifying "This patient is crazy." A pediatrician habitually marked his notes with a smiley face when a young patient had a good-looking mother.

To be sure, most male physicians are good people who are certain that they act in their patients' best interest. They are, however, a product of the values of the male-dominated culture. "The good ole boy called Bubba who becomes a gynecologist is simply Dr. Bubba," says Smith. Moreover, he maintains that a strong subconscious motivation for many men who choose gynecology as a specialty is the "need to be in a powerful and controlling relationship with women."

Whatever sexist attitudes men carry into medical school, they are intensified within the fraternity of physicians. "It's amazing how isolated doctors are," says Smith. "Training doesn't root out their biases and insensitivities. Instead, a subculture envelops them and reinforces each other's stereotypes of patients." A common mnemonic used in medical school to help identify women who develop gallstones is "fat, 40, with four kids." $ Says the author: "It took forever for me to see slender, unmarried women as candidates for gallbladder disease." Prejudiced and mistaken notions also can govern the treatment offered to black women, lesbians and those with a history of venereal disease. For example, says Smith, a doctor quickly diagnosed in a young, married black woman chronic pelvic inflammatory disease -- an ailment that results from previous venereal infection -- though nothing in her history supported such a judgment. Actually, her symptoms and history perfectly matched a diagnosis of endometriosis, a different condition.

As a result of such attitudes, he argues, women are better off with women doctors. Smith concedes that female physicians can be every bit as domineering and money grubbing as their male colleagues and that medical training may drain sensitivity out of some of them, but "as basic material, they have the best opportunity for empathy. And at the least, they understand the female body better than any man could."

Smith knows that his stance is more polemical than practical; no one truly expects men to abandon the gynecological field. Nor should they, as many women patients will attest. That would be the equivalent of saying only male doctors should minister to men and Doogie Howsers to children -- and solely the boys at that. What makes far more sense is Smith's call for a radical restructuring of women's health care. Among his proposals: overhauling medical education so that male doctors understand what it means to be a woman.

By that he means nothing as simple or gimmicky as having men climb into the stirrups, a tactic that is being tried in a few medical schools. "What I'm talking about is a rigorous exposure to the female perspective on life and males, how vulnerable they feel in the world, not just in the doctor's office," explains Smith. "A woman's specialist needs to go beyond anatomy, beyond having babies and periods. He or she needs to be an expert in female sexuality, social interaction, cultural values, anxieties and fears, the total psychological makeup of being a woman." They would also be trained in how such ailments as heart disease and cancer differ in women and men.

Smith believes that the new woman's specialist should concentrate almost exclusively on preventive and primary care. "The ideal setup would be female clinics, overseen by doctors but staffed by nurses and other non-M.D. professionals," he says. Routine prenatal and pregnancy care, now the purview of the gynecologist-obstetrician, would be handled by midwives, while high- risk pregnancies and deliveries would be assigned to the appropriate specialists.

How is this change going to come about? Well, don't count on physicians. "We've got an entrenched older establishment that doesn't see the need for change," Smith observes. "Younger physicians are more likely to favor it but less likely to be politically active." Women are going to have to prod doctors into giving them better care. Smith suggests that women approach their gynecologists "the way you do car dealers and insurance salesmen." Ask questions, he says, and take notes. Your doctor may mark down such assertive action in his medical records. But as a measure of respect, it beats a smiley face every time.