During the COVID-19 pandemic, while some people learned to bake bread and my family made the dubious choice of adopting a high-anxiety poodle who bites, superstar author Lisa See spotted an unopened book on her shelf about women’s medicine in Imperial China. In a fortuitous chain of discovery, Ms. See stumbled upon the name of Tan Yuxiang, a lady doctor during the Ming Dynasty, who published a book of her medical cases in the year 1511. A quick internet search revealed that one could quickly procure a translated copy of Miscellaneous Records of a Female Doctor, and the author’s next project was born. In 2023, the author published her bestselling novel, Lady Tan’s Circle of Women (Scribner). I have enjoyed Ms. See’s work since 2005 when I read her novel Snowflower and The Secret Fan. As a female physician, I found the detailed description of foot-binding of young women to be shocking. This was the custom of breaking the bones of the feet of young girls by binding them tightly to change the shape and size into what they called lotus feet.
Bound feet were a status symbol and feature of feminine beauty. Men found lotus feet to be irresistible. The practice was regarded as a virtuous sacrifice that girls made for their future husbands. Only in 1912 was this barbaric practice banned in China. Ms. See tells the story of Lady Tan’s life in imaginative, yet historically correct detail. She weaves some of the medical cases from Lady Tan’s book into the multiple storylines of her novel. The reader learns much about the practice of Chinese medicine in this early era. Male physicians were not permitted to speak to, touch, or examine women. All interactions were done through an intermediary. Not surprisingly, centuries prior to the discovery of antibiotics and aseptic technique, women did not fare well in the Chinese medical system. Ms. See references a quote from a Han Dynasty official from 15 centuries earlier: In women’s central affair of childbirth, 10 women die for every one that survives. In an era where bad outcomes in general medical care and childbirth were blamed directly on the physician or midwife, male physicians were reluctant to take on the complexities of women’s health care.
During the pandemic, I also researched and wrote a book titled Changing How We Think About Difficult Patients: A Guide for Physicians and Health Care Professionals (American Association for Physician Leadership). When I was reading Lady Tan’s Circle of Women, one line really caught my attention. Lady Tan’s expertise at treating ladies is recognized as unique, so she is called on to travel a great distance to treat a special patient within the Forbidden City. In preparation, Lady Tan goes to her cherished mentors, her grandfather and grandmother who were both learned and respected practitioners of medicine. Her grandfather offered this guidance: Even if the patient is the emperor’s favorite concubine, don’t forget that she is no different from any other woman, 10 times more difficult to treat than any man. In the fictionalized world of 16th-century China, author Lisa See knew male physicians struggled to understand the emotions of their female patients in addition to their unique medical issues.
Difficult patients identified in Imperial China
Not surprisingly, physicians in antiquity considered their female patients to be difficult. Male physicians in China correctly recognized the complexity of women’s health (menstrual cycles, childbirth, the postpartum period, and menopause) to be far more challenging to treat than the medical issues of men. Additionally, the foot-binding process left women highly susceptible to infections and death from sepsis. Women with bound feet had abnormal calf muscle atrophy, which left them unstable for walking and highly prone to injury.
In my book, I discuss the groundbreaking article published in the New England Journal of Medicine in 1978 by Dr. James Groves titled Taking Care of the Hateful Patient. Groves was a consulting psychiatrist at Massachusetts General Hospital in the 1970s who may have been the first to address the fact that treating certain types of patients elicited strong feelings of inadequacy and resentment in the physicians providing their care. A group from Tel Aviv University reviewed Dr. Groves’ original article and updated the issues for modern physicians in the European Journal of Medicine in 2006. Their article, The Hateful Patient Revisited: Relevance for 21st Century Medicine, raised the issues of gender, age, and cultural factors in relation to challenging physician-patient interactions.
White males, who comprised most physicians trained in the 20th century, were more likely to identify women and people of color as difficult. What we now know about differing verbal and nonverbal communication styles between men and women and among different races, ethnicities, and cultures likely contributed to the challenges perceived in these physician-patient interactions. Dermatology texts did not accurately reflect the appearance of rashes and lesions on people with dark skin tones. The gentlemen physicians could not understand the drama and high emotions in many of their female patients. They could not experience the pain of childbirth or the discomfort of monthly menses. The presence of the reproductive organs in the pelvis complicated the diagnosis of medical and surgical problems near the pelvis. Women have other, complicated medical and surgical potential problems to untangle and comprehend.
For centuries, physicians did not even try to understand their female patients; they just labeled women as hysterical. The term is derived from the Greek word hystera, meaning womb. In antiquity, it was used to describe conditions affecting women, particularly those believed to be caused by the movement of the uterus, known as the wandering womb. This concept was first introduced by the OG, ancient Greek physician Hippocrates.
Times have changed and although women often feel dismissed, their lady doctors now know how it feels to have menstrual cramps, labor pains, hot flashes, and insomnia. More than half of the medical school students in our country are female. According to the Women in Academia Report, women continue to represent the majority of U.S. medical school students. Women’s medical problems are challenging to diagnose and treat because we are so complex. We have more diagnoses in the differential list, and we have big emotions to go along with them. We need our nurses and physicians to lean in and to find out why we are having the pain, the cramping, or all those other frustrating symptoms. If the ladies are frightened, we need to find out why. If they don’t understand why they should consent to the treatment, we need to explain it again in terms that they can understand.
Lady Tan made it her lifetime mission to treat the girls and women in her community, regardless of their place in society. Then she documented her case findings and recorded them for future generations of healers. Of course, many of her beliefs about disease transmission and treatment were antiquated and disproven over the centuries. The ancient healers knew about certain plants and practices that would address infections centuries before scientists discovered microbes and antimicrobials. The important thing we can learn from Lady Tan was the strength of her personal mission to heal and her persistence despite the whole sexist and classist structure of society that worked against her. Some of our patients have challenging illnesses and personalities that we must learn to accept and treat with more curiosity and empathy. We can make this our mission even in a system that feels stacked against us too.
Joan Naidorf is an emergency physician and author of Changing How We Think about Difficult Patients: A Guide for Physicians and Healthcare Professionals.
