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A man is twice as likely to leave a doctor's office with a recommendation for knee-replacement surgery as a woman reporting the same level of pain, according to new research.

When Canadian doctors are surveyed, they report that a patient's gender has no effect on their decision-making. But studies have found that more eligible women are going without the surgery than men, so a Toronto research team led by then-PhD candidate Cornelia Borkhoff, took their work undercover to look for bias.

Mimicking mystery shopping research, which relies on unidentified shoppers to report on the service of retailers, Dr. Borkhoff sent two "mystery" patients, one woman and one man, with moderate knee osteoarthritis and the same level of pain to Ontario doctors.

At the time of the study, which is in this week's Canadian Medical Association Journal, the female patient was on a waiting list for surgery.

Of 67 physicians - 29 orthopedic surgeons and 38 family doctors - 67 per cent recommended total knee replacement to the male patient, but only 33 recommended it to the female patient.

"I don't think physicians are withholding treatment after an accurate diagnosis," says Dr. Borkhoff, who completed the research as a PhD student in the University of Toronto faculty of medicine's clinical epidemiology program.

"They're just not recognizing the seriousness of women's symptoms."

The reason has less to do with conscious discrimination than a subconscious bias, she says.

While she and her colleagues believe that physicians want to do what's right for their patients, "... we recognize, too, that doctors are human," she says. "And they're susceptible to the same social stereotyping that affects all of our behaviour."

Because only 12 doctors of the study's sample were women, Dr. Borkhoff says, she was unable to analyze whether the gender of the doctor was a factor, though she suspects that the stereotypes involved are as widely held among women as men.

"We all live in the same society. I think we as women possess the same stereotypes," she says.

For instance, many of us assume that most men are reluctant to visit a doctor, so that when he does, "it must really be bad."

Another possibility is that many doctors wrongly assume that women don't benefit as much from this surgery as men.

It's a misperception that happens to be partially true, and is thus tricky to untangle: Research has shown that women are more likely to be recommended for surgery when their osteoarthritis is at a more advanced stage, says Dr. Borkhoff. Those operations tend to be less successful than ones performed at an earlier stage.

"It's like a vicious cycle," she says, adding that if you compare the success rates of men and women heading into surgery at the same stage of the disease, women do just as well as men.

Another reason for the bias may come from the patients themselves. Women tend to have a more narrative style when describing symptoms to doctors, while men rely on a business-like approach. But Dr. Borkhoff believes that even if this is true, it played only a small role in her findings.

Dr. Borkhoff will now be turning her sights on exploring solutions as part of a post-doctoral fellowship, splitting her time between the University of Ottawa and the New Women's College Hospital in Toronto. One idea is to help physicians recognize their biases.

"People can't really change them [their biases] unless they're made aware of them," she says.

Patients might also benefit from tools such as educational videos about potential treatments available to them.

With osteoarthritis, in particular, Dr. Borkhoff says her research highlights another issue: family physicians' relative inability to detect potential surgery candidates, regardless of gender. Ninety per cent of the orthopedic surgeons compared with 60 per cent of family physicians considered at least one of the mystery patients good candidates for surgery.

"For family physicians, we need to help them to learn to recognize an appropriate candidate," she says. "They are so bombarded with looking after so many aspects of the person's health - heart health, high blood pressure, they are limited [in] the amount of time they can devote to musculoskeletal disease."

The patient scenario

A sample of what the mystery patients told doctors:

Aged 67 years, with right knee pain that began three years ago.

Moderate, intermittent pain that became worse in the past six months.

Minimal interference with normal daily activities.

Complete limitation with vigorous activities.

Physiotherapy and one cortisone shot failed to bring relief.

Earlier X-ray tests showed results consistent with moderate osteoarthritis.

At the end of their appointments, the patients asked the doctors: "Do you think I need a new knee?"

Source: Canadian Medical Association Journal