Gender differences in the clinical competence of residents in internal medicine

OBJECTIVE: To study the differences between cognitive and noncognitive skills of men and those of women entering internal medicine. DESIGN: Comparison of program directors' ratings of overall clinical competence and its specific components and pass rates for men and women taking the Certifying Examinations in Internal Medicine in 1984-1987. PARTICIPANTS: 14,340 U.S. and Canadian graduates taking the Certifying Examinations of the American Board of Internal Medicine for the first time in 1984-1987. MEASUREMENTS/RESULTS: Average program directors' ratings of overall competence were 6.70-6.78 for men and 6.60-6.71 for women. The greatest differences in ratings of specific components of competence were in the areas of medical knowledge and procedural skills, where men were rated higher than women, and humanistic qualities, where women were rated higher than men. Pass rates were stable over the four years of the study, and ranged from 85 to 86% for men and from 79 to 81% for women. Men consistently performed slightly better than women regardless of the type of residency or quality of medical school attended. CONCLUSIONS: Small but consistent differences were found in the performances of men and those of women completing training in Internal Medicine as measured by program directors' ratings and ABIM Certifying Examination performances.     

Gender differences in arrhythmias

Electrocardiographic and electrophysiologic differences between men and women have long been noted. Women have a higher intrinsic heart rate than men, along with a longer corrected QT interval and a shorter sinus nodal recovery time. The incidence of and risk factors for a variety of arrhythmias differ between men and women. Atrioventricular nodal reentry tachycardia has a 2:1 female-to-male predominance, while accessory pathways are twice as frequent in men. Although atrial fibrillation is more prevalent in men of all age groups, the absolute numbers of men and women with atrial fibrillation are equal, and the associated morbidity and mortality experienced by women with atrial fibrillation appear to be worse. Women have a lower incidence of sudden cardiac death, and female survivors of sudden cardiac death have a lower frequency of spontaneous or inducible ventricular tachycardia. On the other hand, drug-induced torsade de pointes and symptomatic long QT syndrome have a female predominance. Therefore, greater caution should be used when prescribing QT-prolonging drugs in women. The incidence of arrhythmias is increased during pregnancy, and management of pregnant patients poses a significant challenge. The mechanisms of these gender differences are unclear but may be related to hormonal effects and the shorter QT interval in adult males. Pharmacologic and nonpharmacologic therapies are usually equally efficacious, but the risks of pharmacologic therapy are different in men and women. Atrial fibrillation may be more difficult to treat in women.     

Gender differences in gastroenterology

Balancing professional and personal life can be particularly challenging for young women at the prime of their reproductive years. Young female gastroenterologists were found to work for larger groups, take fewer calls, and receive less compensation than their male counterparts. Getting more women into gastroenterology will be an achievable goal if the needs of female trainees are understood and met.     

Gender differences in psychopharmacology

At least half of all patients with psychiatric disorders are female. Depressive disorders occur twice as often in women than in men. Despite the need for a gender-specific approach in treating psychiatric disorders, little is known about gender issues in psychopharmacology. It has been recognized that women respond better than men to serotonin-modulating substances but that this effect is reversed after menopause. Furthermore, women develop gynecological complications under medication with certain psychopharmacological agents which calls the use of these drugs into question. Side effects such as weight gain, hyperglycemia, cardiac arrhythmias, and sexual dysfunction also occur more frequently in women than in men. Pregnancy is a particularly sensitive aspect. The risk that a mother with a psychiatric disorder could relapse if the drug is discontinued has to be weighed against the risk of the child being born with an anomaly or developing prenatal complications.     

Gender differences in vascular reactivity of aortas from rats with and without portal hypertension

BACKGROUND: Inflammatory responses related to portal hypertension may be different in male and female rats. Most experimental studies of portal hypertension have involved male animals, and little information is available on gender differences in this setting. The aim of the present study was to compare aortic reactivity in female and male rats with and without portal hypertension. METHODS: Contraction response curves to phenylephrine were studied with aortic rings, with and without endothelium. For relaxation studies, rings were precontracted with phenylephrine 10(-7) mol/L and then exposed to acetylcholine 10(-4) mol/L. Portal hypertension was provoked by calibrated portal stenosis performed 2 weeks before experiments. RESULTS: In non-hypertensive conditions, the contractile response to increasing phenylephrine concentrations was significantly stronger in rings from male than female rats, both with and without endothelium. In male rats with portal hypertension, the phenylephrine concentration-response curves were lowered and shifted to the right in aortic rings both with and without endothelium. In female rats, portal hypertension did not induce significant changes in the phenylephrine concentration-response curves. In female rats, portal hypertension induced a marked increase in relaxation (157 +/- 123% vs 81 +/- 64% in controls); the increase was also stronger than that in male rats with portal hypertension (95 +/- 6%; P < 0.01). CONCLUSION: Clear gender differences were observed in vasoconstrictor responsiveness of aortic rings from rats with and without portal hypertension. Contrary that in male rats, portal hypertension did not induce vascular hyporesponsiveness in female rats. Further investigations are required to explain these differences.     

Gender differences in axial spondyloarthritis

Within the concept of axial spondyloarthritis(ax Sp A), relevant differences between men and women have been described for patients with the radiographic disease form [ankylosing spondylitis(AS)]. The subjective perception of disease activity(spinal and peripheral pain, fatigue, morning stiffness) has been shown to be higher in female than in male patients. Moreover, women experience more functional limitations and a lower quality of life, despite lower degrees of radiographic spinal damage. Peripheral clinical involvement(arthritis and enthesitis) is, additionally, more predominant in women. On the other hand, a higher level of objective signs of inflammation(C-reactive protein, erythrocyte sedimentation rate, magnetic resonance imaging of sacroiliac joints and spine) has been reported in men. Whether these differences might explain the better response to treatment with anti-tumor necrosis factor agents observed in male patients remains unclear. The underlying causes of the discrepancies are still unknown and genetic, environmental, cultural and/or societal factors may be involved. While AS is still more prevalent in men in a ratio of 2-3:1, the prevalence of males and females in patients with ax Sp A without radiographic sacroiliac damage is similar. Gender differences in this subgroup of patients have not been adequately addressed, and are particularly needed to further validate the Assessment of Spondylo Arthritis international Society classification criteria.     

Gender differences in lung growth

Annual measurements of lung volumes and forced expiratory flows were made in 281 boys and girls from 8 to 12 years and in another cohort of 287 from 12 to 20 years to measure longitudinal lung growth. Gender differences in growth of lung function were documented, with girls generating greater volume-standardized maximal expiratory flows until age 18.5 years. Beyond that age boys generated higher expiratory flows in proportion to total lung capacity (TLC). There was a time lag of up to 1 year between the age of peak growth velocity in lung volume and peak growth velocity in height. Age at peak growth in flow lagged another year behind that in volume. This was noted more in boys than girls. Dysanaptic lung growth was found with differing rates of growth of maximal expiratory flow compared with TLC or vital capacity (VC). © 1995 Wiley-Liss, Inc.     

Gender differences in sleep disorders

PURPOSE OF REVIEW: To evaluate recent evidence regarding gender differences in sleep. RECENT FINDINGS: Women have better sleep quality compared with men, with longer sleep times, shorter sleep-onset latency and higher sleep efficiency. Despite this, women have more sleep-related complaints than men. The amount of slow-wave sleep decreases with age in men and women. Normal physiologic periods, including puberty, menstruation, pregnancy, and menopause, are associated with alterations in sleep patterns. Gender differences in normal sleep may underlie the observed differences in risk of sleep disorders. Studies of insomnia support a female predominance, with increased divergence of prevalence between men and women with older age. Recent findings for the gender differences in obstructive sleep apnea have focused on differences in local neuromuscular reflexes and central ventilatory control. Restless legs syndrome has a slight female predominance, whereas rapid eye movement sleep behavior disorder and Kleine-Levin syndrome are more common in men. SUMMARY: Gender differences in sleep become apparent after the onset of puberty. Menstrual cycles, pregnancy, and menopause can alter sleep architecture. Gender-related differences in sleep disorders, such as obstructive sleep apnea, insomnia, and restless legs syndrome, include differences in prevalence, pathophysiology, clinical presentation, and response to therapy.     

Gender differences in orthostatic hypotension

Orthostatic hypotension is a decrease in systolic blood pressure of more than 20 mm Hg or a decrease in diastolic blood pressure of at least 10 mm Hg, within 3 minutes of changing from a supine to an upright position. The typical clinical presentation of orthostatic hypotension includes dizziness, syncope, blurry vision and loss of balance. Symptoms may be more frequent in women, but the complicating roles played by comorbid factors and the estrogen mechanisms are not well understood. Women have a more active parasympathetic system, higher estrogen levels and a lower center of gravity. Thus, women less effectively compensate for the drop of blood pressure in response to positional change. An understanding of these mechanisms contributing to orthostatic hypotension may improve diagnosis and treatment of the problem.     

Gender differences in growth of vascular smooth muscle cells isolated from hypertensive and normotensive rats

Higher male sensitivity to atherosclerotic and hypertensive events was a reason to study sex differences in migration and proliferation of vascular smooth muscle cells (VSMC) isolated from male and female spontaneously hypertensive rats (SHR) and Wistar-Kyoto (WKY) controls. Outgrowth of cells from explants, doubling time, curves of cumulative labeling and the length of cell cycle were measured in aortic VSMC. Systolic and mean arterial pressures were higher in males than in females of the two strains. The migration of cells from male explants was significantly faster than those from female aortas in both strains. The doubling time was always shorter in male VSMC than in those from females and this was more apparent in the late exponential phase of growth. The thymidine incorporation into newly synthesized DNA, which was enhanced in SHR compared to WKY cells, was also higher in male cells compared to female ones. Cell cycle was always shorter in male than in female VSMC due to the shorter G1 phase. In contrast, shorter S phase caused shorter cell cycle in SHR compared to WKY VSMC. Consequently, the shortest cell cycle was found in VSMC from SHR males with the highest blood pressure. It can be concluded that gender and genotype are two independent factors participating in the control of migration and proliferation of VSMC.     

Gender related differences in predictors of vascular complications: role of vessel size and BMI

Women undergoing cardiac catheterization have an increased risk of vascular complications (VC) compared to men. Whether this is due to gender differences in common femoral artery (CFA) anatomy remains unknown. Therefore, we examined angiographic features of CFA to identify differences in predictors of VC between the genders. A case control study design enrolled 59 (30 women and 29 men) consecutive patients with VC and 59 age, gender and procedure matched controls from 2004 to 2009. VC were defined as hematoma >6 cm, any access site related bleeding requiring transfusion or injury requiring mechanical intervention. Quantitative angiography was performed on all femoral angiograms. Univariate and multivariate regression was performed to define clinical and angiographic predictors of VC. Among all patients, cases had significantly lower BMI than controls (28.4 ± 7.7 vs. 32.0 ± 6.7, p ≤ 0.01) and were more than twice likely to have CFA reference vessel diameter <5.5 mm (p = 0.04). This finding was entirely driven by the inverse relationship between BMI, CFA and VC among women. On multivariate analysis, BMI was a potent predictor of VC (OR 0.94; 95 % CI 0.89–0.99; p = 0.04). When comparing men and women, BMI and CFA size were predictors of VC among women only. Among men, site of arteriotomy and diabetes mellitus predicted risk of VC. Smaller BMI correlates with smaller CFA diameter and both are predictive of increased risk of VC. This may explain the female predisposition to VC. Risk stratification for bleeding and VC should address these gender specific findings.     

Gender differences in counterregulation to hypoglycaemia

Summary To investigate the effect of gender on catecholamine responses to hypoglycaemia, single-step euglycaemic-hypoglycaemic clamps have been performed in 14 healthy men and 17 women. Adrenaline responses were 44% lower in females (p<0.01) and noradrenaline 17% lower (p=0.08). In response to low-dose intravenous insulin infusion (0.3 mU · kg^–1 · min^–1), plasma glucose fall and counter-regulation in seven men and seven women had a different course (p<0.001), with different glucose kinetics. In men, endogenous glucose output recovered quickly to levels that exceeded basal; in women suppression of endogenous glucose output was more prolonged, without rates ever exceeding basal (p<0.05). Peripheral glucose uptake was stimulated in men only. The hormones of acute glucose counter-regulation (catecholamines and glucagon) did not differ between the sexes during this challenge, the catecholamine response in the women being supported by the continuous fall in plasma glucose. These results suggest that: 1) catecholamine responses to moderately controlled hypoglycaemia are diminished in women, and 2) Peripheral insulin sensitivity in men is enhanced over that of women but hepatic sensitivity to insulin may be greater in women.     

Gender differences in cellular response.

Autoimmune and other diseases frequently manifest a sexual discordance that cannot be explained by hormonal differences. Although there is evidence for gender skewing being caused by gonadal hormones, such skewing does not explain an increase of frequency rather than of severity of such diseases in women. To examine if skewing might have a genetic explanation, we have asked how male and female cells devoid of hormonal differences respond to challenges. We used mouse embryonic cells from heart, liver and brain and assessed cellular responsiveness by cell survival. We find that female cells in general show more sensitivity to challenges, such as ethanol, hydrogen peroxide, and camptothecin. Our findings indicate that there is a differential behavior to challenges, in male vs female cells, which may be due to differences in the biological make-up of the cells with regard to gender, and provide preliminary information regarding the feasibility of this type of approach.