Why women get overlooked in healthcare—with Serena Williams

Amy Barnes: I don't ask a doctor to be warm and fuzzy. I don't ask them to hold my hand every day. I ask them to be really good at their job. But part of being really good at your job is to listen to your patients, to what they're saying to you.

Rachel Thomas: Welcome to Tilted, a Lean In Podcast. Each week, we explore the uneven playing field—the gender bias that lurks in unexpected places, the impact it has on our everyday lives, and what happens when women lean in and start driving change. I’m your host Rachel Thomas, co-founder and president of Lean In.

Rachel: As an athlete, Serena Williams needs no introduction. Roger Federer, who knows a thing or two about tennis, says she's the greatest player of all time. She's won 23 grand slam titles and counting. And she's done more than any player to redefine women's tennis as a sport of power and athleticism. But we're actually not here to talk about sports today. We're here to talk about the terrible health scare you experienced after the birth of your daughter, Olympia, and about how bias in healthcare affects too many women. Serena, thank you so much for your time today.

Serena Williams: Thank you.

Rachel: So, let's start with the birth of Olympia. Tell us about that day.

Serena: It was a magical day. Actually, I went in at 39 weeks because I have had prior health issues with PE’s and DVT’s as well, so I went in at 39 weeks and then I got induced or lightly induced. They just started the process and I started having contractions and then I was like “oh my god, I'm going to have a baby, this is really happening, I can't believe this is happening.” So, the day of really was a wonderful experience.

Rachel: And how long have you struggled with both issues?

Serena: So I had my first DVT in 2003, after I had knee surgery. Typically you get it after you have surgery, or it could be genetic.

Rachel: And are these blood clots, basically?

Serena: These are blood clots, yeah. And blood clots have a tendency to travel if they’re not treated immediately. So, if they’re swelling in the leg, or you’re walking and then for no reason you’re getting shorter breath, those are typically signs that you might have either a blood clot or a pulmonary embolism or a DVT.

Rachel: So, that is an unfortunate segue into what happened after Olympia was born. I know that you suffered a lot of medical complications. Can you walk us through what happened?

Serena: So, after Olympia was born, I had some serious medical complications. I ended up having to have an emergency c-section, which was totally unexpected. And after that, I just remember being short of breath and I couldn't breathe. And I remember telling the doctor, “OK I need a C.T. scan with dye, so we can get a look at my lung because I feel like I have some PE’s in there.”

Rachel: He didn’t quite listen to you immediately, did he?

Serena: Well, I had a female doctor.

Rachel: Oh, ok.

Serena: And actually, the nurse didn't understand what I was saying and she thought it was obvious that the medicine was making me because I had a c-section, I was on medicine. She thought the medicine was making me loopy and I was like, “No, I'm really clear, I'm telling you exactly what I need.” Actually, my doctor was very responsive. And they ordered different tests that I was like, “No I don't need this test, I need a CT scan.” A lot of doctors don't understand that patients really know their body, we live on our bodies every day. And it's really important for them to listen to us.

Rachel: You felt initially not really listened to?

Serena: Other doctors didn't understand what I was saying, but my personal doctor that delivered the baby, she understood straight away. When you have a c-section, there's more than one doctor that comes in, there's different people and you're in a hospital and different doctors come in to check on you for different types of things. And she was the only doctor that really heard, and was really able to listen to me. And it pretty much helped save my life. It was pretty impressive.

Rachel: And by the way, I have to go on record - I'm so angry at myself for saying he and assuming your doctor was a man. I'm glad she was a woman and I'm glad she listened when the other doctors weren't. And then what happened, you had a couple really tough weeks?

Serena: Yeah, I had some crazy tough weeks. I ended up having to have four surgeries in the hospital because I couldn't breathe, I wasn't getting enough oxygen to my lungs, and by all the trauma of the coughing, which sounds weird but when you have a c-section, coughing is the most painful thing ever. And I just remember crying and saying “I can't, I can't breathe, I can't cough.” Finally, I just had a cough and I had all these towels, holding my wound because every time I cough, it would just hurt, and then eventually it busted the stitches and then I had to go back to get that repaired, and then I developed a hematoma, which was bleeding on the inside. And then somewhere along the line, the doctors ended up putting something in my veins to keep blood clots from my from my heart and my lungs. And it was hard because I was so happy to be there with the baby and I was kind of out for half the time that she was there, I ended up being at the hospital for a week. It wasn't the experience that I was expecting, but at the end of the day I did get to take my baby home, and we just had the best time. But through this whole experience, I realized, especially with the pregnancy part, that a lot of women, especially black women, aren’t listened to, and the rate that black women are dying and the mortality rate of moms is not shocking, it’s actually frightening. And that’s why I thought, “this is a great way to raise my voice.” I've heard so many women say, “oh, by the way, this was my experience.” And it was so similar to mine, but the doctors didn't understand what I needed. And unfortunately, I think because of who I am and because I've had so many injuries and because I really understand my body, and I had the best doctor I feel like I could have had, she listened to me, but the others around didn't. But it was just like if she wasn't there, and a lot of women don't have that doctor that can be so supportive.

Rachel: So, for those of you who don’t know, black women in the United States are over three times more likely to die from pregnancy or childbirth related causes. And we should just all be shocked hearing that. That is just unacceptable.

Serena: It is unacceptable, three times black women suffering mortality rates, and like I said before, it’s frightening. It's beyond shocking. It's scary. It's like, “OK because of the color of my skin, my doctor probably won't listen to me as well or, I don't know the reason, but something's happening in terms of we are not getting the same health care, we're not getting the same advantages, we're not getting just treated equally. It’s a frightening thing. It’s 2018, it's almost 2019, and we're living in a country that is super advanced technically and it's just, how do we have a stat like that? It’s sad.

Rachel: I agree, and I think it’s all those reasons. It's access to health care, it's insurance, it’s having their voices heard. Yes, so much has to change to get this right. So, you've said something already, but I'd like to go back at it. I mean, you’re Serena Williams, you’re world famous, you have some of the best doctors and hospitals in the world, what can other women do, what's your recommendation for how they can lift up their voice in the moment and be heard?

Serena: I don't have the answer to that, I wish I did. I think what I can do is continue to raise my voice and maybe some doctor out there, even if it's one or two, hears me maybe they'll go into the office the rest of their careers and they'll think differently while they're treating their patient, or while they're with their patient. As for our ladies out there, just keep using your voice and be firm and really be insistent, just keep knocking and knocking and knocking, eventually so will answer. And don't be afraid to speak up because this is your life, it really matters.

Rachel: I'm thrilled to be here with Dr. Janine Clayton, Director of the Office of Research on Women's Health for the National Institutes of Health. She's the author of over eighty scientific publications, journal articles, and book chapters, and an expert on the role of sex and gender in health and disease. Thank you so much for joining me.

Dr. Janine Clayton: Thank you for having me.

Rachel: Dr. Clayton, can you tell us a little bit about your background to get started? And, in particular, what led you to commit to studying sex and gender in healthcare.

Dr. Clayton: Sure, I'm actually an ophthalmologist by training, so I'm an eye doctor and was doing clinical research here at NIH studying diseases that affect both women and men. In fact, I was studying autoimmune diseases that affect women more than men. But, the reason I started doing what I do now is because I realized that two thirds of the people that are visually impaired, or blind, in the world are women. That's two thirds of the people in the United States that are blind are women. And the scary thought is, we had no idea why that is. Women do live longer than men do, and so age is a risk factor for most eye diseases, but that doesn't explain all the difference. The fact that we couldn't explain that, despite our research efforts, for many, many years really disturbed me and that got me interested in the role of sex and gender in health and disease.

Rachel: So, I have to ask...have we discovered why women are more likely to have issues with vision than men?

Dr. Clayton: Well, the good news is, we know that because of differences in the immune system, the female immune system is actually more robust and vigorous than the male immune system. That makes us at increased risk for all autoimmune diseases, including those in the eye. The bad news is, we don't know about all the other diseases that affect women more than men, so, there's much more work to be done there.

Rachel: So, now you run the Office of Research on Women’s Health at the NIH, which was formed in 1990 to ensure women were included in clinical research studies. What was medical research like before then, and what’s changed?

Dr. Clayton: Well, before 1990, women were not routinely included in clinical trials of medications used to treat diseases that affect both men and women. In fact, women were actively excluded from those studies, and so, when a study was performed to test a medication...

Rachel: Ok wait, sorry, let me jump in for one second.

Dr. Clayton: Sure.

Rachel: What do you mean by “actively excluded”?

Dr. Clayton: So, they were prohibited from participating in such studies. For example, there are inclusion and exclusion criteria for entering a study and being a woman was actually an exclusion criterion at that time.

Rachel: Forgive me, but why would that be?!

Dr. Clayton: So, at that point in time, we really had a limited understanding of the fact that you could not study men and apply those findings to women. We just didn't know that. We thought that the findings from men would be relevant to women and so, we were protecting women by not including them. So, women might get pregnant during the study. There was a concern about harming developing babies. And there really was not this understanding that sex, being male or female, has such a profound effect on your health and your disease status.

Rachel: Wow, OK. That is so interesting. I know you, in your own work, you draw an important distinction between the health of women and women’s health. Why is that distinction so important?

Dr. Clayton: In the past, women's health was interpreted to mean, basically bikini medicine. And by that, I mean care of those parts that are covered by a bikini. Today, we know that women's health is everything that affects a woman from head to toe.

Rachel: What are the implications of changing from thinking about women’s health to the health of women?

Dr. Clayton: So, imagine a 50-year-old woman and she might come in to the emergency room saying that her heart feels like it's racing and you might ask her, does she have a history of heart disease? And that's important. More often than not, somebody might ask her if she is anxious or stressed and whether these are really just palpitations from that. If you're coming from a health of women perspective, you're going to think about the entire experience of that woman in the context of her life. It's also important to take into consideration the age of a woman because we know that certain transitions in life are really important. For example, that same 50-year-old woman, you might need to ask her, did she have any complications when she was pregnant? Did she have pregnancy induced hypertension or pre-eclampsia? High blood pressure during pregnancy? Because that makes her an increased risk for cardiovascular disease later in life. So we like to think of a life course perspective as an integrated continuum of a person's life, not just separate developmental stages of life.

Rachel: So, we know that medical research often excluded women, and we know that for too often, we were focused on a very narrow definition of women’s health and how to think about it. What does that mean? How often are women misdiagnosed? How often is it still happening? What are the types of diseases or ailments that are most misdiagnosed? Walk me through as much of that as you can.

Dr. Clayton: You asked about whether women are misdiagnosed, and I would say often under-diagnosed or even not diagnosed at all. It may be because the way that we employ the tests that we use to diagnose a disease were based on studies that were done in men, or were targeted on disease patterns that occur predominantly in men. So, I'll give you an example. The gold standard tests for detecting heart disease or coronary artery disease is called a coronary angiogram. That test detects a very clear pattern of narrowed areas in the major blood vessels in your heart. Unfortunately, sometimes women have heart disease that has a pattern that has normal large coronary arteries, normal coronary angiogram, but abnormal small blood vessels or micro-vascular disease. So, the diagnostic tests that we use as the gold standard are more likely to detect the pattern of disease that is more typical for men.

Rachel: So, cardiovascular disease. Am I right, it kills more women than men each year, doesn’t it?

Dr. Clayton: You’re right. More women than men die of heart disease every year in the United States. I talked about how women might show up with heart disease differently than men and so we need to develop tests that are better to detect the patterns of disease that women might have, the symptoms that women might report. In fact, women do have the classic crushing chest pain, it feels like an elephant standing on my chest. And those are not hard to diagnose, right? If somebody says that, you know they're having a heart attack. The problem is, a woman might just come in and say, “I've been really tired for the last two weeks. I'm a little short of breath when I go up like five flights of stairs, instead of my usual seven, and my jaw is really hurting.” That actually, by itself, can be a woman experiencing low oxygen in her heart and she's basically getting ready to have a heart attack. And we want to pick up a woman at that point and prevent her from having the heart attack.

Rachel: And do doctors sometimes they’ve got a mistake, right? Shortness of breath and jaw...it’s not hard to imagine they mistake it for something else. Is that true?

Dr. Clayton: So, you have symptoms that are very nonspecific shortness of breath. Could be asthma, could be a lung infection, could be an allergic reaction. Pain in the jaw or pain with swallowing, could be a sore throat, that's a viral infection. So, those symptoms being so nonspecific make it a little harder to actually diagnose a woman who may be having a heart attack coming into the emergency room. But, what we want to do is we want to make sure, and this is a term we use a medicine, that you have a high index of suspicion, that you think about, “is this a heart attack?” when you have a 55 year old woman who's standing in front of you and says, “this is not how I am normally.” We also want to make sure that women say to their care providers, “something's not right.” We often know something's not right with our bodies. And if that's not your normal, it's really important to advocate for yourself and to let the care providers know this isn't right.

Rachel: That is such a good point. So, a couple weeks ago, I sat down with Serena Williams. And she suffered a pulmonary embolism and she had deep vein thrombosis after the birth of her daughter. And she told a really, a pretty shocking story that most of the nurses and doctors around didn’t really listen to her, and take her self-assessment seriously. As you probably know, Serena’s become very outspoken around the dangers that women of color often face as they go through pregnancy and they have children, and how high the mortality rate is in this country. Why?

Dr. Clayton: I actually showed a slide very recently showing the U.S. maternal mortality rate going up, and it going down in everywhere else. In fact, our maternal mortality rate exceeds that of Libya, Turkey, and Vietnam. So, we're clearly not doing something right. It's really about listening to women. It's about making sure that women have access to care. It's about our methods of detecting the causes of maternal mortality and morbidity for every woman who actually dies having a baby, there are 10 near misses. There needs to be systemic attention to this issue. After a woman gives birth, all the attention is on the baby, as it is understandably, but there needs to be attention on the woman, too. In the weeks immediately after giving birth, women are at high risk, in some more than others - women of color in particular, African-American women, regardless of income, regardless of access, have a much higher rate of poor outcomes than others.

Rachel: So, is the reason for that biological, or is this really because they are being overlooked in the system?

Dr. Clayton: Great question, and I wish I knew the answer. We don't know why. And that's why NIH is focusing efforts on maternal mortality and morbidity, efforts like the human placenta project, where we are studying the placenta, which we believe has a key role in triggering preeclampsia or pregnancy induced hypertension, we have a whole effort just on studying and understanding the placenta. So, the answer is, we don't have all the answers, but at least we are now asking some of the right questions.

Rachel: So, Doctor, you talked a lot about women being excluded from medical research and that you at the NIH and others have really started to focus on including women in medical research. Can you give us a couple examples of some studies that have been done that were really illuminating and that you think are moving the dial in allowing women to get better healthcare?

Dr. Clayton: Good question. Well, the good news is, now, over half of the participants of NIH supported clinical research are women. The bad news is, the studies are, when they are published in scientific journals, fewer than a third of those publications from the Phase 3, the big clinical trials, have any results for men and women listed separately. So, the women are in the studies, but the results for the women and for the men are not presented always separately in the publications. So, we've been working with journal editors and publishers to advance the notion that those papers really must include results disaggregated by sex. The problem is, if those results are not separated for men and women, we don't know how well the results apply to both men and to women.

Rachel: Is there a study that really stands out to you where the fact that women are now included explicitly in the study and that we have that visibility, it has really changed the way we think about a certain type of disease, or a certain type of illness, and how we think about treating women? I’m looking for a really clear example of why getting this right really matters.

Dr. Clayton: We actually know that nicotine replacement therapy, like gum that has nicotine or a nicotine patch, does not work as well in women as it works in men. So, how might a doctor change their treatment? OK, I'm not saying they're not going to try the nicotine patch or the nicotine gum first because that's a really safe and first step, but if they know that it's less effective in women, they may say, “OK, we're going to try that for four weeks in you.” And if it doesn't work, they may be more prone to move to the next level of treatment more quickly in a woman than in a man. So, it may affect their treatment algorithm because they understand that upfront.

Rachel: Do we know why?

Dr. Clayton: So, we know a lot about sex differences and how men's and women's brains respond to addiction. For example, women become addicted more rapidly than men do when they use cocaine and when they drink alcohol. It's a phenomenon called telescoping. So, a woman could be drinking the exact same amount per body weight as a man does, she's going to become alcohol dependent more rapidly than a man does. And the scarier part is, the same amount of alcohol damages a woman's organs, like her liver and her brain, more than the same amount of alcohol damages a man's brain or liver.

Rachel: So, what’s really interesting to me, and maybe I’m just not reading the right things or watching the right news programs, how do I not know that?

Dr. Clayton: So, we need to do a better job of getting the word out about these differences between men and women. And what you can do, you can keep asking us these questions - is it different for men and women? And that's another thing that I tell anyone in my family, if you're going to get prescribed a medication, ask, “do we know if this drug works differently in men and women, do we know if the adverse effects of this drug are different in men and women?” I used to take a medication every day that is now withdrawn from the market because it has a severe side effect that is more common in women than in men.

Rachel: Thank you so much for your time, Dr. Clayton. I really appreciate it.

Dr. Clayton: Thank you! I appreciate it as well.

Rachel: We’re taking a short break, but we’ll be right back.

Rachel: I am here with Dr. Esther Choo, Emergency Doctor and Associate Professor at Oregon Health and Science University. Her research focuses on women's health and she frequently speaks about racism and sexism in healthcare. Dr. Choo goes by Esther, so I'm going to call her Esther for the interview. Last week, I chatted with Dr. Janine Clayton, who as you know is at the NIH, and she really walked me through the history of women being excluded from medical research. As an emergency doctor, you obviously see how this plays out on the front lines. What’s happening?

Esther: So, we know in all these conditions that I see on a daily basis, women do not fare as well as men. So, for example, we know that women do worse than men in functional outcomes after having a stroke. We know that while the incidence of stroke is decreasing for men, it's increasing for women. We haven't been very good as scientists and as physicians in decreasing the incidence of stroke. And we also know that, when we have defined evidence based therapies for things like heart attack and stroke, they're less likely to be implemented for women. Now, all of these things are multifactorial, but the picture on whole is that we are doing less well for women in healthcare than for men.

Rachel: So, one of the things that was really interesting when I talked to Dr. Clayton, I get that research historically has excluded women, but I was really surprised that even now when studies are done that include women, that’s not included in the published findings. You kind of alluded to this - that it’s not finding its way to doctors that are at the front lines. What’s going on there?

Esther: Yeah, I think there is always a delay from when we start including both male and female sexes and research to having that translate to the bedside when you come into the hospital. And so, in the NIH, I think we're better at getting both male and female rats, for example, into studies. I mean, basic science researchers have to demonstrate that they are considering both male and female rats. So, then you go from rat or mouse models, animal models into human models, you have to show that they don't cause harm, then you can move ahead with larger scale studies and then the research gets published but sometimes, researchers aren't very good at reporting results stratified by sex or gender. And then that research has to get disseminated to healthcare professionals everywhere, and there's the education and dissemination piece, so people know to apply that to their practice. So, the timeline between that first rat study and then coming into the hospital and knowing that that research is being applied, that's many, many years, probably in the order of 15 or 20 years. So, we can improve the science to be more inclusive of female subjects, but we know we've done that so recently that we're really not going to feel the impact of that at the bedside for a long time.

Rachel: So, I have to say, as a woman myself and the mother of a girl, it’s a bit disconcerting to hear how long it's going to take to really see a lot of change - what can we do in the meantime, how can we advocate for ourselves?

Esther: I have a couple of suggestions. I do think that a narrative that I frequently hear from my female relatives and friends is, “I went to the doctor and I felt that my experience was not validated or that I had an idea for what I wanted to happen with my care, with my choice of contraception, with how seriously my complaints are being taken.” And this, to me, at a very qualitative level, seems to be happening much more to my female friends and relatives. And so, a lot of the work that I do is talking about bias towards women and how physicians need to be aware of those and really try to address their implicit biases as they go out in the world and interact with people of different backgrounds. But, there is a piece for now that is sort of on the patient. And so, I think there is some need for women to be strong and not feel bad or guilty about advocating for themselves. A friend of mine coined this phrase, we haven’t proven this with data, but we have this phenomenon where women patients will come in and get a little bit of condescending care, where, usually an older male physician, feels like he knows what’s best for younger female patients. We call it “clinical mansplaining,” where sometimes women don’t feel you..

Rachel: I’m familiar with mansplaining.

Esther: We think there’s a very specific sub-terminology of mansplaining that happens in the clinical exam room, where women feel like their desires and their goals for healthcare a little bit ignored, in the hands of a male physician, who has a sense that they know better than they do about about some of their healthcare choices and it doesn't feel very patient-centered and it seems to happen a lot to women. So, I think we kind of want to start this “down with clinical mansplaining” campaign where women have more agency in the exam room. I think there's another piece that can happen, maybe also slowly but I think we need to really diversify our workforce. There's a good amount of data coming out showing that, first of all, women give excellent care. When we look at major clinical outcomes in the hands of female versus male physicians, we find that females are at least as good, in some circumstances they may outperform men. And I'm not talking about, do patients like having a female doctor, I'm talking about mortality outcomes, 30 day bounceback outcomes. But there was one study, in particular, that really caught my eye. This was published in the Proceedings of the National Academy of Sciences in August of this year, where they found that among heart attack patients admitted to Florida hospitals over a 20 year period, female patients having heart attacks treated by male physicians had higher mortality than female patients treated by female physicians. And then, this study went one step further and they just looked at the proportion of women physicians working in these emergency departments and they found that when there was a higher proportion of women physicians, male physicians did better in outcomes for their female patients having heart attacks. So, in the corporate world, you diversify the workforce in terms of gender and racial and ethnic minorities and you find that your bottom line, which in the corporate world is really your financial returns, they improve. And what we're seeing is, in the healthcare setting, where our bottom line is also money but is primarily patient outcomes, that bottom line improves when you diversify the workforce.

Rachel: So, it’s clear from talking to you that more women physicians is part of the answer, not the whole answer, but part of it. What do you think we can do to encourage women to get into the field? And I think it's happening naturally, but clearly not enough if two thirds of doctors are still men.

Esther: In June of this year the National Academy of Sciences, Engineering and Medicine came out with a report that showed that in academic sciences, there are very high rates of sexual harassment. But, that is worst in medicine and they reported on research that showed that, by the time women graduate from medical school, about 50% of them have experienced sexual harassment. And so, this is a terrible problem. And the report was very good in providing an overview of potential causes of this, but it is clear that it is an organizational problem and that when you have these male-dominated, male-led environments, that is basically a very rich petri dish for harassment to occur and then, they looked at the downstream outcomes of harassment and what we find is that, when you've been sexually harassed, it is the number one thing that impacts women's careers. And then, the other really interesting thing about the outcomes, is it doesn't just affect the women. So, the entire group the woman works in, whether it's her team or her division, or her department, all of that is like a toxin, it kind of spreads from the target of harassment, it spreads out to their entire working group, and actually an entire organization can be poisoned by the occurrence of harassment. When women are harassed, what do they do? I mean it's a very natural, you have organizational disengagement, so, you are not as mentally in the game at your workplace, which is so heartbreaking, when you think about we need women to give good care to women, who gives reproductive health care? Who gives the majority of women's health care? It's women physicians. And yet, we are exposing them to harassment, they're feeling demoralized, they're not as engaged, many of them will step down from leadership positions because of harassment. It really looks like from this report that a good portion of it can probably be explained by the culture of medicine for women. So, I really think we have to do profound change in the culture of healthcare before we can fix the problem of getting more diversification of our workforce, so that we can fix the problem of having poor treatment outcomes for women.

Rachel: So, we’ve talked a bit about medical research. We've talked about having more diverse teams of doctors. Is there anything else that the industry needs to be doing to get better, in terms of giving women equal care?

Esther: There has to be this implementation piece, and so, what inspires hospitals, medical schools, all health professions, really, to advance the science and get excited about integrating this into our practice, in our educational systems. I think, basically, anyone who kind of is in this position of being responsible for hospitals and training institutions meeting these quality requirements, they have to be wired to understanding what drives these disparities and basically, compelling organizations from the outside to show that they have a vested interest in this.

Rachel: Do you have any really specific recommendations for what women can say to their doctors to get them to slow down and take them seriously?

Esther: Yeah, well, when I talk about other types of gender biases that are very prevalent and in particular, any circumstances where women have to negotiate for something, whether it's their salary or their clinical care, it's difficult because you feel like you're working against gender norms and you worry that the other person will not receive it well, I often advise people to draw out the implicit bias. And so, when I'm negotiating or asking for something tough, I often will start by saying something like, “now, I sometimes am perceived as being more assertive than most women and many people will not like me as much because of that. But, I hope that's not the case here. You sort of call out the implicit bias and then explain to them why they're not going to have that same knee jerk reaction to a woman being a little bit more outspoken and assertive about her care. And I often feel that that's disarming, while also very making the potential bias explicit and hopefully evoking a response in that person that, “well, I am, of course, not going to be biased towards you because you're behaving against gender norms.” So, that's just one little tip. I wish I didn't need to tell women to do this, but I sometimes feel like it's necessary and I think calling out the bias can be effective when you really feel like it's there and it doesn't have to be confrontational, it can be a friendly thing that actually makes that person your ally upstream against their potential biases.

Rachel: I like that strategy, we do that a lot as well. We have negotiation recommendations and we always caveat them with, “we wish we didn't have to tell you to do this, but in the meantime, until we improve bias and we improve the system, here's some things that you can do to get better results.” Well, this has been great, I think we covered a lot of ground and I know that I learned a lot. I'm a little depressed but, I think it's really helpful and I hope that the big takeaway for both women and men listening is just to be real advocates for themselves and get educated and ask a lot of questions and poke on things to make sure they're getting good healthcare.

Esther: Totally, I really am so grateful that you're tackling this problem. I think it's something we don't talk about often enough, so it's just thrilling to me that you're doing it.

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Our producer is Jordan Bell. And special thanks to Katie Miserany, Ali Bohrer, Megan Rooney, and Sarah Maisel from the Lean In team and Laura Mayer at Stitcher.

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This has been Tilted, and I’m your host, Rachel Thomas.