Clinical decision making is not necessarily guided by prejudice

EDITOR—The paper by Hippisley-Cox et al makes an important contribution to the literature on sex differences in health service use.1 Primary care physicians act as gatekeepers to specialist health services, yet this critical role in the healthcare system has been largely ignored by researchers in this field.2

Hippisley-Cox et al said that their findings suggest a systematic bias towards men in terms of secondary prevention of ischaemic heart disease. Such a conclusion is premature. The results may reflect biased decision making, but they may also have been determined by patient preferences or mutual agreement between doctor and patient. In common with other research in this area, the charge of biased decision making has been made as a result of a process of exclusion. Once it has been shown that clinical need (in this case a diagnosis of ischaemic heart disease) cannot account for the finding that women are less likely to receive a certain treatment than men (in this case, lipid lowering drugs), then the spectre of bias is raised. It would, however, be preferable to be able to demonstrate positively that clinical decision making is guided by prejudice before making claims that a service is biased.

Prejudice is very difficult to show as clinicians cannot be blinded to the sex of their patients. Alternative methods including the use of clinical vignettes, audiotaping consultations, and analysing individual patient records have been tried, but they have proved inconclusive because of their lack of context. 3 4 Factors shown to affect physician response, including the patient's age, ethnic group …