Exploring the perceptions of senior medical students on gender and pain: a qualitative study of the interplay between formal and hidden curricula

Understandings of pain and gender are shaped by the replication of gendered stereotypes broadly and in clinical practice

This subtheme illuminates the influence of stereotypes, assumptions and biases in this context. During data collection and analysis, it became evident that students’ perceptions were multifaceted and shaped by various factors, including societal and clinical norms, medical school teaching and personal experiences. We explore these influences in greater depth in later themes.

Personal identities shape students’ understanding of the relationship between gender and pain

In this subtheme, we explore how students’ personal experiences, backgrounds and identities play an important role in shaping their understanding of the relationship between gender and pain.

Students noted that where they shared experiences with patients in pain (either experiences of pain personally, or via family and friends’ experiences) they could better empathise with patients. M, for example, describes women in their family being dismissed when in pain–seeing the distress this causes on a personal level, has meant M aspires to take patients’ pain seriously: ‘I’m always like, ‘oh my God no aunty, I swear I’ll take you seriously’…if [a patient] has said, ‘so and so’ and they’re visibly distressed because of it, yes, I think I take that a bit more seriously because I don’t want to be another dismissive doctor’ (M). Students highlighted that their personal experiences of pain management influenced the recommendations they made to patients: ‘That’s affected my suggestions for management… I’m often much more inclined to suggest physio, having been through that experience where… [I was] offered painkillers and nothing else’ (Krishna).

Some women noted that being a woman in pain made it easier to sincerely empathise with other women experiencing pain. Andrea, for example, comments on their personal experiences of gynaecological services and pain as a source of empathy for patients with similar pain, interacting with similar services: ‘Every single month I’m so much pain that I pass out and being like, oh my god. I’m so sorry to hear that, I’m not reading off a script and just writing, here is your mefenamic acid or whatever they give to them. So, I feel like that impacted myself in a professional way but also in a personal way, because it’s like, wow, gynaecological services across the board are bad. Whether you’re a medical student or you’re a patient yourself’ (Andrea).

Similarly, where students shared a particular characteristic with patients, for example, ethnicity, they were more attuned to the intersectional nature of bias in relation to pain and the needs of patients who were like them for example, patients’ cultural norms and how this might influence pain presentation and management. M describes advocating for patients where language barriers are an issue, based on their own experience of this barrier within their family:

I think for anyone who cannot speak English to some degree, probably because I sometimes have to advocate for my own parents and stuff like that, that I feel like I always take what they’re saying seriously… everyone has a bit of unconscious bias when they think, “oh she’s being dramatic or he’s being dramatic”, well that’s not right. And it’s very easy to get into that mindset, but as soon as they can’t speak English I feel like I’m a bit more serious about it, because I feel like I have to be, because I don’t think anyone else is going to give them that benefit of the doubt (M).

Students experience tension between the clinical diagnosis and management of pain, and holistic understandings of pain

Students saw existing curricula as focusing only on the pharmacological management of pain: ‘at all stages it’s generally been focused on the [World Health Organisation] pain ladder’ (Krishna).

This sends a hidden message to students and clinicians—that the focus of clinical practice should be the medical management of pain. This, coupled with a relative lack of holistic teaching on pain management and bias (‘Medicine, at least the way medicine is taught at my university is very much like, if it’s not objective, it’s too difficult to try to make you conceptualise, so we’ll try to avoid that topic’ (Jiva)) leads to an uneasy tension where medical students understand pain both to be objective and physiological, but also to be subjectively experienced by each patient. This causes conflict in clinical practice (‘we have ways of assessing patients’ pain by looking at them, by the way they move, how they act. And we quite often hear people say, ‘oh, they can’t be in that much pain because they’re doing this’… I generally try to look at pain as whatever the patient tells you it is’ (Rory)) and is implicated in previously described views regarding catching patients out who aren’t ‘actually’ in pain (‘I’ve certainly spoken to patients and gone… They’ve said their pain is a nine out of ten. And I’ve gone, I don’t believe you. Obviously, not to the patient. But I’ve walked out the room and gone, I don’t believe you’ (Rory)).

Further, this hidden message contributes to the focus of clinicians (identified by the students) on treating the underlying cause of pain, rather than managing pain itself (‘Doctors prioritise the particular condition or treatment over exploring the pain’ (Aarya)). This can also be connected to the unease students perceived clinicians as feeling when dealing with chronic pain (where an underlying cause may be illusive) (‘It seems people come in for a recurrent pain and they’re just giving you medication and don’t really discuss the impact or the hows and the whys or the self-help’ (Michelle)), pain of psychological origin (‘I think that if someone is in pain and physicians perceive that there isn’t a visible or diagnosable related physical experience that would cause them that level of pain, I don’t think that there is much sympathy for patients’ (Alex)), and subsequent poor management of such patients.

Relatedly, students recognised the need for an enhanced focus on the lived experiences of people who are/have experienced pain. They saw opportunities for an increased focus on patient perspectives (in relation to pain and gender) in case studies, as both a developing strand within spiral curricula models, and through engagement with the arts and humanities: ‘I think it’s best to hear it from and have talked with patients themselves to name their experience. But I think the next best thing would be reading patient accounts, reading poems, reading narratives about what it’s actually like to experience these different kinds of pain’ (Alex).

Students are motivated to engage in learning about the relationship between gender and pain, and their role in addressing key challenges

Many students who were well-informed about gender bias and pain had engaged in significant self-directed learning in their own time, without opportunity to discuss their learning formally with their peers or tutors: ‘All those things I’ve just picked up from external sources, whether it’s on Twitter, or I read a paper on it, it’s never been formally taught to me’ (M).

Students are motivated to learn about pain and gender in a more holistic way and expressed a desire to be part of a conversation regarding the manifestations of gender bias in relation to pain (‘The most important thing is getting people aware of it… making young medics willing to talk about it. Because we’re all educated people. We’re all bright. We’re all, hopefully, kind and compassionate. And if we just would talk about it, we could probably get a decent way to fixing it without massive intervention’ (Peter)); and part of action to challenge identified inequalities (‘The other thing that really is important to me, personally, is what we can do about it…. it gets quite repetitive and quite infuriating… I get the whole point of raising awareness and that it’s important that we know. But what is the point of me…going into clinical practice, knowing that women are generally discriminated against… if I can’t do anything about it?’ (Rory)).

Understandings of pain and gender are shaped by the hidden curriculum’s communication of gendered stereotypes

Gendered stereotypes were present in students’ understanding of pain and were described by students as communicated through the hidden curriculum. Overall, women were perceived as ‘more anxious’ (Lucy) than men, and more likely to ‘moan’ about pain—‘Even the way I’ve just said it, moaning about pain, because that’s what’s ingrained to us’ (Jiva).

Students perceived that women’s pain was more likely to be dismissed clinically: ‘Patients are dismissed based off their pains’ (Aarya); attributed erroneously to gynaecological causes: ‘The amount of times I’ve had to go, ‘are you sure it’s not your period pain?’ I’m pretty sure the 30-year-old who’s been having 18 years, 12 periods a month, 18 years, she’s had over 200 of these things now. I’m pretty sure she knows it isn’t that. Why are we asking?’ (Peter); and psychological origin: ‘… it really saddens me that so many more women are likely to be misdiagnosed with anxiety (Krishna). Where pain was discussed as psychological, it was sometimes associated with women ‘over exaggerating’ (Jiva) pain—as Akira puts it ‘in the ward you learn how to distract the patients away from their pain… how you could divert their attention. It reveals them as well… a patient came in… they were in agony… distract them and then you can tell it’s not too bad’.

The intersectionality of other characteristics, such as race, socioeconomic status, weight and disability status, also played a role in the students’ perceptions of pain. Most students appreciated that bias was intersectional, and that individuals affected by many different types of bias would be most negatively affected in relation to diagnosis, treatment and management of pain: ‘I think working class women of colour are probably the most affected when it comes to pain [management]’ (Jiva); ‘People of lower socioeconomic class, [there’s] a higher assumption they’re drug seeking’ (Peter). Students were often aware of harmful bias relating to race, ethnicity and socioeconomic status and saw this manifest in their teaching and clinical experiences: ‘We’re taught outdated science, like, oh, Black people have a higher tolerance for pain. That’s just frankly a lie that came from no science ever. But it’s still propagated and people still believe’ (Peter).

It is important to note that not all students believed they had encountered gendered stereotypes in relation to pain in clinical practice, or in their university education: ‘I haven’t picked up on patients being treated differently because of gender… the patient’s experiencing pain… you need to give them something to relieve that… their gender or any other specific characteristic isn’t important in that’ (Vanya). Others recognised their lack of familiarity with gender bias may be due to their own limited awareness: ‘Nothing I’ve seen myself… but often you read about things or hear about things other people have seen’ (Kaivalya).

Senior clinicians often role model biased understandings of pain

Senior clinicians’ opinions and actions were greatly influential and are an aspect of the hidden curriculum that impacts student perceptions of gender and pain. Through these opinions and behaviours, students are exposed to negative stereotypes and biases regarding pain and its management in the clinical environment. Students reported witnessing a lack of empathy from clinicians that they suspected was a result of taught (‘Medical school teaches you to dissociate, pain-wise’ (Jiva)) and necessary (‘It’s either detach or let it affect you too much’ (Jiva)) detachment, dismissive attitudes regarding patient pain (‘It has to be very, very severe before anyone takes it seriously’ (Shubhi)). There were many reports of instances where patient pain was inadequately managed, which students suspected to be as a result of bias—Michelle, for example, describes the following:

A young Black woman with sickle cell anaemia came in with the crises… she had a PCA [Patient Controlled Analgesia] set up… and was asking nurses again and again throughout the night and saying that she was pushing the button, she wasn’t getting pain relief… the nurses had been very dismissive and they came in the next morning and they found that the PCA wasn’t connected to the driver, so she’d been pushing this button again and again and obviously it hadn’t done anything at all…that really just shocked me, actually, that a ward that’s so pro… when given a young Black woman with a known terrible disease that needs adequate pain relief, they seemed to be just disbelieving her (Michelle).

Some students discussed bias in pain relating to disability status and weight and noted negative assumptions among senior clinicians, for example, if someone can mobilise, they are not in pain; if someone is fat, they could be doing more to improve their lifestyle and manage their pain. Akira comments on the management of pain in primary care: ‘… they’re like, I can walk with a walking stick, and so maybe they [the General Practitioner] perceive their chronic pain less of a major thing’; whilst Alex notes bias regarding patients’ weight and doctors’ perceptions of lifestyle changes ‘…. that culture of, well, if you hadn’t let yourself get like this then you wouldn’t be in pain’.

For some students, witnessing the negative role modelling from their seniors motivated them to behave differently: ‘My whole experience on that placement made me feel like I would never do that to my patients. I would never, even if I’m so busy and I’m running an hour late in my clinic, I’m never going to rush through a speculum exam. Because it can be traumatic’ (Andrea). However, this was not echoed in all student accounts.