Imagine you’re having a heart attack.
You hurry into the emergency department, frightened and hoping someone recognizes what’s happening before permanent damage occurs. The physician evaluating you has spent years learning how heart attacks present, which tests matter, and which treatments save lives. Every decision is grounded in decades of research and generations of physicians who painstakingly built modern medicine.
There’s just one problem. The patient who taught medicine what a heart attack looked like probably didn’t look much like you.
That isn’t an indictment of medicine. It’s simply the way science evolved. Every scientific discipline begins by simplifying an impossibly complicated world. Physicists imagine frictionless surfaces. Economists imagine perfectly rational consumers. Medicine, for much of the twentieth century, imagined a reasonably healthy adult man.¹ Researchers weren’t trying to ignore women, children, or older adults; they were trying to answer extraordinarily difficult questions while controlling as many variables as possible. Pregnancy raised understandable ethical concerns after the thalidomide tragedy, hormonal cycles complicated study design, and adult men gradually became the scientific reference point against which everyone else was compared.²
It was a logical place to begin. It simply wasn’t where the story ended.
As physicians accumulated experience, patients kept arriving who didn’t quite fit the picture. Women described heart attacks that looked different from the ones in the textbooks. Children became ill in ways adults didn’t. Patients from different cultures described the same diseases differently. Conditions that had long been dismissed as “stress” or “just anxiety” gradually acquired names, biological explanations, and, perhaps most importantly, legitimacy. Medicine hadn’t failed. It had simply reached the limits of a model that had become too narrow.³
That realization was captured perfectly by Bernadine Healy, the cardiologist and former Director of the National Institutes of Health, in her landmark 1991 essay describing what she called the Yentl Syndrome. Women, she argued, often had to become “honorary men” before receiving the same diagnostic evaluation and treatment as male patients.⁴ Her point wasn’t really about cardiology. It was about what happens whenever we mistake the typical patient for the universal one.
More than a century ago, Will Rogers observed, “It isn’t what we don’t know that gives us trouble; it’s what we know that ain’t so.” Few quotations capture the history of medicine more elegantly. The remarkable story isn’t that previous generations of physicians were wrong. It’s that they kept asking whether yesterday’s assumptions still explained today’s patients. That willingness to question itself has quietly transformed modern medicine. We’ve learned that biological sex influences everything from heart disease to medication metabolism, that children cannot be understood as miniature adults, and that culture, trauma, poverty, loneliness, and chronic stress all shape the way illness develops and is experienced.⁵
The story of modern medicine isn’t one of failure. It’s a story of expanding vision. Some of its greatest advances haven’t come from discovering new diseases. They’ve come from finally seeing the patients who had been there all along.
The Heart Attack That Changed the Textbook
If there was one disease that finally forced medicine to question whether the “average patient” really existed, it was heart disease.
For generations, physicians learned to recognize a heart attack almost instinctively. A middle-aged man develops crushing chest pain that radiates down his left arm, breaks into a cold sweat, and collapses. The image became so familiar that Hollywood adopted it, too. Ask almost anyone to act out a heart attack and chances are they’ll perform exactly that scene.
The problem wasn’t that the picture was wrong. The problem was that it wasn’t complete.
Heart disease has long been the leading cause of death for both men and women, yet much of what physicians understood about heart attacks came from studies conducted primarily in men.⁶ As researchers broadened those studies, they discovered that many women certainly experienced the classic symptoms, but many others arrived describing overwhelming fatigue, nausea, shortness of breath, pain in the jaw, neck, shoulders, or back, or simply the unsettling conviction that something was terribly wrong.⁷ Too often those symptoms were attributed to anxiety, menopause, indigestion, or stress before anyone considered the heart.
As Marianne Legato likes to remind physicians, “Every cell has a sex.”⁸ It sounds almost obvious today, but it represented a profound shift in thinking. Once researchers stopped asking whether women looked like men and started asking how women actually experienced disease, they discovered differences extending far beyond heart attacks. Hormones, immune systems, metabolism, blood vessels, and even responses to medications all turned out to be more complex than medicine had appreciated. The heart hadn’t changed. Our understanding of it had.
As a psychiatrist, I’ve always found another discovery equally fascinating because it reminds us how artificial the boundary between physical and mental illness has always been. For years, physicians viewed depression largely as something that developed after a heart attack. We now know the relationship works in both directions. Depression increases the risk of developing cardiovascular disease, predicts poorer recovery after a heart attack, and increases the likelihood of future cardiac events. Conversely, surviving a heart attack substantially increases the risk of depression and anxiety.⁹ The heart and the brain are in constant conversation through hormones, inflammation, the autonomic nervous system, sleep, and behavior. Cardiology and psychiatry have never been studying separate stories. They’ve been reading different chapters of the same book.
That relationship becomes especially striking in Takotsubo cardiomyopathy, the so-called “broken-heart syndrome,” which occurs overwhelmingly in women.¹⁰ Intense emotional stress can temporarily weaken the heart muscle so dramatically that patients arrive in the emergency department appearing to have a heart attack. For centuries, stories of people dying from grief sounded like poetry. Modern cardiology has shown they can also be physiology.
That may be why Robin Williams‘ observation that “Everyone you meet is fighting a battle you know nothing about” feels so timeless. The woman apologizing for “making a fuss” may be having a myocardial infarction. The man insisting he’s “fine” may be profoundly depressed. The patient sitting quietly in the waiting room is almost always carrying far more than the symptoms we first notice.
• Heart disease remains the leading cause of death among women in the United States.⁶
• Depression approximately doubles the risk of developing coronary heart disease.⁹
• Women continue to experience delays in the recognition and treatment of heart attacks compared with men.⁶
The heart didn’t simply teach medicine that women sometimes have different symptoms. It reminded us that every time we widen our picture of the patient, our picture of disease becomes a little more accurate.
When Pain Doesn’t Show Up on a Blood Test
If heart disease taught medicine that it had been looking for too narrow a picture of a heart attack, pain forced it to confront an even more unsettling possibility: what if the patient understood the illness before medicine did?
Medicine has always been most comfortable with diseases it can see. A fracture appears on an X-ray. Diabetes announces itself through a blood test. Pneumonia leaves fingerprints on a chest film. Pain is different. It can’t be photographed, biopsied, or measured under a microscope. It exists only in the person experiencing it, leaving physicians to depend on something medicine has always viewed with equal parts respect and skepticism: the patient’s own story.⁷. That uncertainty has consequences.
When symptoms don’t fit the medical model of the moment, it’s often easier to question the patient than the model itself. For generations, women describing pain were more likely than men to have their symptoms attributed to stress, anxiety, or emotional distress before anyone considered that the science itself might be incomplete.⁸ Many spent years moving from one physician to another, accumulating normal laboratory tests while never accumulating an explanation.
Looking back, it’s remarkable how many of those patients turned out to be right.
Endometriosis, affecting roughly one in ten women during their reproductive years, can cause debilitating pelvic pain, infertility, bowel symptoms, and profound fatigue, yet many women still wait years before receiving a diagnosis.¹⁰ Similar stories have unfolded with migraine, autoimmune diseases, postural orthostatic tachycardia syndrome (POTS), myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), fibromyalgia, and hypermobile Ehlers-Danlos syndrome. None of these illnesses suddenly appeared during the past few decades. Medicine simply became better at recognizing what patients had been describing all along.
As a psychiatrist, I’ve always found this especially fascinating because my specialty has often been placed on the wrong side of a false choice. Patients are frequently told an illness is either “medical” or “psychiatric,” as though the brain exists outside the rest of the body. It doesn’t. Anxiety can produce chest pain, dizziness, nausea, palpitations, gastrointestinal distress, and profound fatigue. Depression often hurts physically. Trauma changes the way the nervous system processes pain. At the same time, chronic pain reshapes the brain itself, increasing the risks of depression, anxiety disorders, insomnia, substance use disorders, and suicide.¹¹ The illness influences the brain, the brain influences the illness, and after a while the distinction becomes less useful than the conversation between them.
That’s why I’ve never liked the phrase, “It’s just anxiety.” Sometimes anxiety is the diagnosis. Sometimes it’s the consequence of years spent living with an illness no one else can see. More often, it’s woven into both. Good medicine doesn’t ask whether suffering belongs to the body or the mind. It asks how the two became so intertwined in the first place.
After being diagnosed with breast cancer, Tig Notaro walked onto a comedy stage and opened with four unforgettable words: “Hello. I have cancer.” The audience laughed, then grew quiet, then laughed again. Somehow she transformed one of the worst moments of her life into an evening about connection rather than disease. Physicians try to do something similar. We begin by listening to stories that don’t yet make sense, trusting that today’s mystery may become tomorrow’s diagnosis.
More than a century ago, William Osler offered advice that has only grown wiser with time: “Listen to the patient. He is telling you the diagnosis.”¹¹ Medicine has become extraordinarily sophisticated at sequencing genomes, interpreting MRI scans, and measuring molecules our predecessors never imagined. One of its greatest advances, however, has been rediscovering something much older. Patients often know something is wrong long before science understands why.
• Women account for nearly 80% of patients with autoimmune diseases.¹⁰
• Migraine affects women about three times as often as men.¹⁰
• The average delay in diagnosing endometriosis is still measured in years, not months.¹⁰
Medicine didn’t discover these diseases because they suddenly appeared. It discovered them because it finally learned to listen.
Children Weren’t Just Smaller Adults
As medicine gradually realized that women weren’t simply smaller men, it was forced to abandon another assumption that had survived just as long: children weren’t simply smaller adults.
That seems obvious today, but it wasn’t always. Many medications prescribed to children were originally studied only in adults, with doses adjusted according to body weight and the hope that biology would cooperate.²⁷ Eventually physicians recognized that the real difference wasn’t size. It was development. A child’s brain, immune system, metabolism, hormones, and even the way illness is expressed change continuously throughout childhood.¹²
I learned that lesson during my Child and Adolescent Psychiatry Fellowship at NewYork-Presbyterian Hospital. Like every psychiatry fellow, I had already spent years immersed in adult psychiatry before I was finally “allowed” to learn about children. I’ve often thought that sequence was backwards. We don’t ask pediatric cardiologists to master adult cardiology before they’re permitted to care for children, yet psychiatry has traditionally assumed that understanding the adult naturally prepares us to understand the child. It doesn’t.
I had the privilege of training with several extraordinary attending physicians, each of whom shaped the way I think about patients. One doctor who influenced me most was Jonathan Slater. What made him remarkable wasn’t simply his knowledge. It was the ease with which he entered a child’s world without expecting the child to enter his. He taught me that one of the most common mistakes young psychiatrists make is waiting for children to describe their illnesses the way adults do. They rarely do.
Adults usually arrive with stories. They describe sadness, hopelessness, panic, racing thoughts, or difficulty concentrating. Children communicate through behavior. Depression may look like irritability. Anxiety may masquerade as stomachaches, tantrums, or refusing to go to school. Emotional distress often appears first in the classroom, on the playground, or around the dinner table, long before it appears in words. Once I understood that, I realized I wasn’t learning a younger version of adult psychiatry. I was learning an entirely different language.
That shift in perspective changed far more than child psychiatry. For years, the image of ADHD was the little boy who couldn’t stay in his seat, interrupted everyone, and somehow involved the entire classroom in whatever he was doing. Girls often escaped notice because their symptoms were quieter and easier to hide. Many worked harder, stayed quieter, and exhausted themselves trying to appear organized while privately wondering why everything seemed so much harder for them than everyone else.¹³ Autism followed a similar path. Because much of the early research focused on boys, generations of girls became remarkably skilled at masking, carefully studying facial expressions, rehearsing conversations, and copying classmates until they appeared socially effortless. By the time they came home, many were emotionally depleted.¹⁴
Ironically, the better they became at hiding their struggles, the less likely anyone was to recognize they needed help. Of course, medicine has also had to learn the opposite lesson: not every energetic child has ADHD, just as not every shy child has autism. I was reminded of that recently when an energetic eight-year-old spent our appointment bouncing enthusiastically from one toy to another before proudly announcing, “That’s my ADHD.” Maybe. Or maybe that’s simply what being eight looks like on a Tuesday afternoon. One of the hardest jobs in child psychiatry isn’t recognizing illness. It’s recognizing healthy development.
As John Mulaney once joked, he had “the energy of someone who’s hiding a gun.” Every teacher smiles because they’ve known that child. Every parent has wondered whether that child needs help. Most eventually become perfectly healthy adults. Distinguishing personality, temperament, development, and disease remains one of medicine’s most difficult, and most humbling, responsibilities.
The more medicine learned to see children on their own terms, the more accurate it became. Childhood hadn’t changed. Medicine had finally learned its language.
The Patient Never Arrives Alone
One of the reasons I pursued a Master’s in Public Health was that I wanted to understand illness before patients ever reached my office. Medical school had taught me how diseases work. Public health asked a different question: Why did this particular person become sick while someone else didn’t? That question has quietly shaped the way I’ve practiced medicine ever since.
By the time someone sits across from me and says, “Doctor, something’s wrong,” they aren’t bringing me a diagnosis in isolation. They’re bringing a lifetime. Their biology has already been influenced by where they grew up, what they ate, whether they felt safe as children, whether they had stable housing, meaningful relationships, access to healthcare, chronic stress, trauma, loneliness, or simply enough sleep.¹⁵ Patients don’t arrive carrying only their genes. They arrive carrying their biographies.
Psychiatry makes that impossible to ignore. Two patients with the same diagnosis of depression may describe entirely different illnesses. One talks about overwhelming sadness, another about headaches, exhaustion, stomach pain, or the conviction that something is physically wrong. Neither patient is mistaken. They’re describing the same suffering through the language their brains, bodies, families, and cultures have taught them to speak.¹⁶
For years, medicine framed these questions as nature versus nurture, as though biology and experience were competing explanations. Increasingly, they’ve become impossible to separate. The emerging science of epigenetics suggests that chronic stress, early adversity, nutrition, exercise, sleep, pollution, and social isolation can influence how genes are expressed without changing the DNA itself.¹⁷ Our biology isn’t simply something we’re born with. It’s something our lives continually shape.
That’s one of the reasons I find psychiatry so hopeful. The same brain altered by adversity can also be altered by recovery. Medication, psychotherapy, restorative sleep, exercise, meaningful relationships, purpose, and simply the passage of time don’t merely change how people feel. They change the organ producing those feelings. The brain, like every other organ, responds to the environment in which it lives.
More than 175 years ago, Rudolf Virchow wrote that “Medicine is a social science, and politics is nothing else but medicine on a large scale.”¹⁸ Whether or not one agrees with the second half of that sentence, the first has only become more persuasive. Physicians don’t treat diseases that exist apart from the people who have them. We treat human beings whose biology has been shaped by their experiences, and whose experiences continue shaping their biology every day.
Perhaps that’s been medicine’s greatest evolution. It hasn’t simply become better at understanding diseases. It’s become better at understanding people.
So...Who Was Medicine Built For?
By now, the answer to the title’s question is probably less controversial than it first appeared. Medicine wasn’t built for men so much as it was built starting with men.
That wasn’t the result of a conspiracy or even a conscious decision. It was simply how science evolved. Researchers simplified extraordinarily complicated problems, controlled as many variables as they could, and gradually expanded their understanding as new evidence emerged. For much of the twentieth century, the adult male became medicine’s reference point because he was, at the time, the most practical place to begin.¹⁹
The remarkable part of the story isn’t that medicine started there. It’s that it refused to stay there.
As physicians widened their view, they discovered that women weren’t experiencing “atypical” heart attacks; the textbook had simply been incomplete. Children weren’t speaking an immature version of adult psychiatry but an entirely different developmental language. Patients living with chronic pain weren’t imagining illnesses; they were describing conditions medicine had not yet learned to recognize. Public health reminded us that genes tell only part of the story, while childhood, culture, relationships, trauma, opportunity, and environment spend a lifetime shaping the rest.
Looking back, what impresses me most isn’t how much medicine once missed. It’s how willing it has been to admit that it missed it. Perhaps that’s why Will Rogers‘ observation still feels so modern: “It isn’t what we don’t know that gives us trouble; it’s what we know that ain’t so.” Science has never depended on always being right. It depends on remaining curious enough to question what we think we already know.
Medicine continues to do exactly that. Today’s students will almost certainly discover blind spots that seem obvious a generation from now, just as today’s physicians continue to uncover diseases, treatments, and patterns their teachers could never have imagined.
That’s not a weakness. It’s the scientific method doing exactly what it was designed to do. The greatest advances in medicine haven’t always come from inventing better tests or more powerful medications. Sometimes they’ve come from something much simpler. Looking more carefully at the patient sitting in front of us.
Notes & Sources
1. Caroline Criado Perez. Invisible Women: Data Bias in a World Designed for Men. Abrams Press, 2019.
2. Institute of Medicine. Women and Health Research: Ethical and Legal Issues of Including Women in Clinical Studies. National Academies Press, 1994.
3. Marianne J. Legato, ed. Principles of Gender-Specific Medicine. 3rd ed. Academic Press, 2017.
4. Bernadine Healy. “The Yentl Syndrome.” New England Journal of Medicine. 325(4):274-276, 1991.
5. Institute of Medicine. Exploring the Biological Contributions to Human Health: Does Sex Matter? National Academies Press, 2001.
6. American Heart Association. Heart Disease and Stroke Statistics (most recent scientific statement).
7. Marianne J. Legato. Eve’s Rib: The New Science of Gender-Specific Medicine and How It Can Save Your Life. Harmony Books, 2002.
8. Robert M. Carney & Kenneth E. Freedland. “Depression and Coronary Heart Disease.” Nature Reviews Cardiology. 2017; Diane E. Hoffmann & Anita J. Tarzian. “The Girl Who Cried Pain: A Bias Against Women in the Treatment of Pain.” Journal of Law, Medicine & Ethics. 2001.
9. C. Noel Bairey Merz, et al. “Women and Ischemic Heart Disease.” Journal of the American College of Cardiology; reviews of Takotsubo cardiomyopathy in Circulation and the Journal of the American College of Cardiology.
10. Hugh S. Taylor, et al. “Endometriosis.” Nature Reviews Disease Primers.; M.C. Hayter & M.C. Cook. “Updated Assessment of the Prevalence, Spectrum and Case Definition of Autoimmune Disease.” Autoimmunity Reviews.
11. William Osler. Aequanimitas, with Other Addresses to Medical Students, Nurses and Practitioners of Medicine. P. Blakiston’s Son & Co., 1904.
12. Institute of Medicine. Safe and Effective Medicines for Children. National Academies Press, 2012.
13. Stephen P. Hinshaw & Katherine Ellison. ADHD: What Everyone Needs to Know. Oxford University Press, 2016.
14. Sarah Hendrickx. Women and Girls on the Autism Spectrum. Jessica Kingsley Publishers, 2015.
15. Arthur Kleinman. The Illness Narratives: Suffering, Healing, and the Human Condition. Basic Books, 1988.
16. Robert M. Sapolsky. Behave: The Biology of Humans at Our Best and Worst. Penguin Books, 2017.
17. Michael Marmot. The Health Gap: The Challenge of an Unequal World. Bloomsbury, 2015.
18. Rudolf Virchow. Collected Essays on Public Health and Epidemiology (translated selections).
19. National Academies of Sciences, Engineering, and Medicine. Sex and Gender Differences in Health and Disease: Moving from Bench to Bedside. National Academies Press, 2022.
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