Viewpoint

Surface versus Structure: The longstanding issue of the gender pay gap in medicine

By Krystal Jacques

The issue of the gender pay gap is frequently forgotten by today’s society but is still pervasive across various fields of work today. A 2019 report by StatsCan revealed that Canadian women earn 0.87 cents for every dollar earned by men. 1 And the gap starts early, according to a new report that tracked the earnings of Canadian post-secondary graduates across 11 fields of study (including college, bachelors, masters, and doctoral degrees). Women earned less than men in every field, with an average gap of $5,700 (12% less than men) in the 1st year after graduation, which increased to $17,000 (25% less than men) after 5 years.2 Ontario’s gender pay gap has narrowed significantly since 1987 when the provincial government first passed the Pay Equity Act. But according to a 2019 report by Glassdoor, it will take 164 years to close the gender wage gap in Canada.3

At present , jobs that mirror traditional “women’s work” (e.g. administrative, early childhood educators) tend to be undervalued because they parallel domestic work that women were (and are) expected to perform for free. Whether the gender pay gap exists in higher paying careers, such as medicine, is a contentious issue. According to a 2020 U.S. report, a pay gap between male and female physicians at the outset of their careers not only exists, but is actually growing.4 The starting salaries of female doctors were on average $36, 618 lower than male doctors from 1999 to 2017.4 Here, we will discuss the possible reasons for the gender pay gap in medicine-a field historically dominated by men that continues to be plagued by in-built institutional gender bias.

A recently published study in JAMA Neurosurgery analyzed 1.5 million surgical procedures from the start of 2014 through 2016; it found female surgeons in Ontario earn 24% less than their male counterparts, and the proportion of women performing an operation decreased as the pay per hour for that procedure increased.5 A similar article by the Association of American Medical Colleges (AAMC) summarizing gender-based pay disparities in medicine from several resources in the Unities States (U.S.) was published a few months earlier. These articles bring into awareness the many possible reasons for why this gender pay gap is occurring: 1) women tend to have less aggressive billing behaviours than men, 2) men tend to refuse the less lucrative medical procedures, while women tend to say yes to any opportunity they can get, 3) female physicians tend not to self-promote or negotiate salary, and 4) women tend to choose the lower paying, less lucrative specialties after their training (i.e. Gynecology). 5,6 Out of all female surgeons in Ontario included in the analysis, 49% of them practiced gynecology.7 In the U.S., the percentage of female surgeons working in gynecology versus the more lucrative urology is 54% and 8% respectively.6 According to AAMC specialty data, 63% of pediatricians in the U.S. are women, whereas 95% of orthopedic surgeons are men. Also, the majority of neurosurgeons are men.5 On the surface, women tend to be less aggressive than men when it comes to self-promotion, negotiation for higher salary, getting the biggest bang for their hours, and choosing the highest paying specialties.

“female surgeons in Ontario earn 24% less than their male counterparts, and the proportion of women performing an operation decreased as the pay per hour for that procedure increased. ”

However, the 2020 study showing a gender gap in starting salaries for physicians found that work-life balance preferences (eg. predictable hours, length of the workday, frequency of being on-call overnight or on weekends) accounted for less than 1 percent of the pay gap, and had no effect on the differences in starting salary. 4 Why are men paid more than women out of the gate? The authors say differences in specialty and the number of job offers received may explain some, but not all, of the gap.

Some believe the gender-pay gap is attributable to a difference in skill-that male surgeons are just “more capable”. However, the recent Ontario study found that in almost all cases, female and male surgeons took the same amount of time to perform identical procedures, debunking the myth that females are just “less competent” or that they work less efficiently than men. Although it may be the case that women value flexibility over lucrativeness when pursuing medicine (due to the increased demands of domestic, child and elder-care socially expected from women), the gaps also persist within speciality. Particularly in male dominated specialties. In a paper published in 2017, researchers compared Relative Value Unites (RVUs – a system of work compensation implemented primarily by U.S. medicare) between gynecologic and urologic procedures performed in the U.S. They found that 84% of procedures were compensated at a higher rate for male-specific procedures. For example, a biopsy of the prostate is worth 4.61 RVUs while a biopsy of the endometrium is 1.53 RVUs. 8

Even more nefarious is the fact that the same procedure-a total urethrectomy-has different RVUs depending on whether it is performed on a man or a woman. For men, it is 16.85; for women, 13.72. Although we cannot completely rule out the possibility that the procedure is inherently more difficult when performed on men than on women (research on this is limited), Parangi, an MD at Harvard Medical School, and the main interviewee of the AAMC article, suspects that the real reason for these RVU differences reflect a male-dominated structure in medicine, contending that, “The committee that establishes RVUs has 30 voting members. Only two are female.”5 Similarly, the Ontario study found that female surgeons receive fewer referrals overall.7 The reason behind this is suspected to be implicit bias.9 The authors of the Ontario study told the Globe and Mail that a possible solution to this is to pool all the referrals for each specialty and distribute them in an unbiased system.6

Besides the inherent male-bias in the structure of the medical system, research and personal experiences would suggest that differences in ambition and assertiveness is a reflection of a cultural and societal artifact. It is well documented that in childhood, girls are typically taught to be less aggressive and less confident, while boys are taught the opposite. 10,11 And what seems like incompetence in female surgeons could just be lack of confidence. So how can we address this gender-pay disparity in medicine?

First, we must address institutional bias by ensuring the real-world gender ratio of medical practitioners is reflected in the governing bodies and committees who make decisions. Another solution could be putting systems into place making it impossible for surgeons to refuse lower paying procedures. But it also means we must teach all children, regardless of gender, to be confident in their skills and capabilities. Many women choose to reduce their hours to start a family, however new fathers are less likely to do so. Fathers should also be encouraged by society to share the responsibilities of childcare equitably with their partner. Perhaps this would allow women to reduce their hours by a little less or return to work more quickly after maternal leave.

Last, it is important not to forget that there are many in our world that perceive women as lazy or incompetent. We see the term “lazy” also used to describe disparities in work compensation between races. Women of colour, Indigenous women, and women with disabilities are even more worse off than white woman when it comes to the gender pay gap overall. 12 For example, in the U.S, black male doctors make an average of $50,000 less per annum than white male doctors, while black female doctors make almost $100,000 less than black male doctors. 13 It is pivotal that we also study the intersections between race and gender to address the gender pay gap issue more thoroughly and implement solutions that ensure all women are paid fairly.

References 1. Accenture. Accenture Study Finds Growing Demand for Digital

Health Services Revolutionizing Delivery Models: Patients, Do [Internet]. Newsroom. Accenture; 2018 [cited 2019Nov7]. Available from: https://newsroom.accenture.com/news/accenture-studyfinds-growing-demand-for-digital-health-services-revolutionizingdelivery-models-patients-doctors-machines.htm. 2. Perez S. IDC: Apple led wearables market in 2018, with 46.2M of the total 172.2M devices shipped [Internet]. TechCrunch. TechCrunch; 2019 [cited 2019Nov7]. Available from: https:// techcrunch.com/2019/03/05/idc-apple-led-wearables-market-in2018-with-46-2m-of-the-total-172-2m-devices-shipped/. 3. Apple. Apple announces three groundbreaking health studies [Internet]. Apple Newsroom. 2019 [cited 2019Nov7]. Available from: https://www.apple.com/ca/newsroom/2019/09/appleannounces-three-groundbreaking-health-studies/ 4. Fitbit. Fitbit to Be Acquired by Google [Internet]. Press Release

Details. 2019 [cited 2019 Nov7]. Available from: https://investor.

Fitbit.com/press/press-releases/default.aspx 5. Cyrcadia Health. Core Technology [Internet]. Cyrcadia Health. [cited 2019Nov7]. Available from: http://cyrcadiahealth.com/ core-technology/ 6. Microsoft. Project Emma [Internet]. Microsoft Research. 2017 [cited 2019Nov7]. Available from: https://www.microsoft.com/ en-us/research/project/project-emma/ 7. Philips. Wireless Wearable Biosensor for Vital Signs Monitoring:

Philips Healthcare [Internet]. Philips. [cited 2019Nov7]. Available from: https://www.usa.philips.com/healthcare/clinical-solutions/ early-warning-scoring/wireless-biosensor 8. Tran V-T, Riveros C, Ravaud P. Patients’ views of wearable devices and AI in healthcare: findings from the ComPaRe e-cohort. npj Digital Medicine [Internet]. 2019Jun14;2(1). Available from: https:// www.nature.com/articles/s41746-019-0132-y 9. Izmailova ES, Wagner JA, Perakslis ED. Wearable Devices in

Clinical Trials: Hype and Hypothesis. Clinical Pharmacology & Therapeutics [Internet]. 2018Apr2;104(1):42–52. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6032822/ 10. Center for Devices and Radiological Health. Consumers (Medical

Devices) [Internet]. U.S. Food and Drug Administration. FDA; [cited 2019Nov25]. Available from: https://www.fda.gov/ medical-devices/resources-you-medical-devices/consumersmedical-devices#What_is_the_difference_between_Cleared_and_

Approved_ 11. PricewaterhouseCoopers. PwC Canada’s Consumer insights survey:

The experience is pertinent to Canadian consumers [Internet]. PwC. 2019 [cited 2019Nov25]. Available from: https://www.pwc. com/ca/en/media/release/canada-consumer-insights-survey.html 12. Canada H. Government of Canada [Internet]. Canada.ca.

Government of Canada; 2018 [cited 2019Nov25]. Available from: https://www.canada.ca/en/health-canada/services/drugs-healthproducts/medical-devices/activities/announcements/notice-digitalhealth-technologies.html 13. Bowling A. Mode of questionnaire administration can have serious effects on data quality. Journal of Public Health. 2005May3;27(3):281–91.

Cannabidiol! The new magic elixir, the miracle drug, cure to every possible ailment you can think of. Whether you suffer from depression, anxiety, psychosis, epilepsy, arthritis, migraines, dry skin, insomnia, an opiate addiction or the unrelenting pain from high heels – this wonder drug can heal all, adherents claim. Over the past two years cannabidiol products have exploded into mainstream markets, with certain health enthusiasts and social media influencers treating the compound as the new “cure-all”. By Mashal Ahmed

Cannabidiol, or CBD, is a major cannabinoid constituent of Cannabis plants. However, unlike THC (tetrahydrocannabinol)—the primary psychoactive compound in many cannabis products—CBD does not produce any psychoactive or mind-altering symptoms.1 Whereas THC often induces anxiety and psychosis-like effects, CBD tends to reverse them. In fact, research suggests that CBD has the potential for multiple beneficial health improvements, including neuroprotective, anti-inflammatory, antiepileptic, antianxiety and antipsychotic effects.1

In 2018, the high-profile case of Billy Caldwell drew CBD into the media spotlight. Thirteen-year old Caldwell of Northern Ireland suffers from treatmentresistant epilepsy and relies on a CBD-based medication to control his seizures. He made headlines last year when his imported medication was confiscated at a London airport; medicinal cannabis was illegal in the UK at the time. This case resulted in a fierce public debate on medicinal cannabis use and its health benefits.2 In November 2018, prescribed medicinal cannabis was finally legalized in the UK for patients with exceptional clinical needs. Caldwell’s medicine, Epidolex, is a purified CBD extract made specifically to treat individuals with severe forms of epilepsy. Two recent clinical trials showed that epileptic patients treated with Epidolex had significantly greater reduction in the frequency of atonic seizures compared to patients treated with placebo.3,⁴

CBD has also become a major drug of interest in the field of mental health, that patients treated with CBD showed significant improvement in psychotic symptoms compared to those treated with placebo. The CBD-treated group also demonstrated a trend for cognitive improvement, with no major side effects from the drug.⁵ In an interview with The Guardian he called CBD “the hottest new medicine in mental health”. Although optimistic, Dr. McGuire is still cautious about the current findings, noting that larger scale and longer-term clinical trials are needed before CBD can be introduced as a formal antipsychotic.

Despite the need for further clinical investigation, CBD products have exploded beyond the clinical realm into the larger over-the-counter marketspace in the past two years. “CBD” and “hemp-based” have

...company and consumer claims all lack one important detail: empirical evidence.

with studies suggesting mild to moderate improvements in anxiety and psychotic disorders.1 Dr. Philip McGuire, professor of psychiatry at King’s College London, has been studying CBD for over 15 years. His recent clinical trial investigated the effects of CBD on patients with schizophrenia.⁵ Results of this randomized, placebocontrolled, double-blinded study showed become buzzwords, especially amongst upscale beauty brands. Product sales are now projected to reach $22 billion USD by 2022.⁷ This projected growth is largely due to CBD’s status as a health and wellness product; a quality highly desired by the growing body of health-conscious modern-day consumers looking for the “organic” option.

Latching on to shifting consumer trends, hemp-based health boutiques are popping up everywhere, offering a line-up of oils, lotions, and pastes to please the CBD craze. Danielle Blair, owner of Torontobased Calyx Wellness, offers an array of CBD products in addition to other holistic remedies such as crystal healing and reiki. Her business aims to create open, informative dialogue about CBD therapies and make such natural remedies more accessible in the Canadian health and wellness market.8 However, the CBD frenzy has expanded beyond small businesses to the mainstream market. You can now find CBD-infused into just about anything. Products range from CBD soaps, toothpastes, and chewing-gum to truffles, spring water, alcoholic beverages, and even CBD-infused pillowcases. While some companies claim their products provide a sense of calmness, others say their products help individuals become more focused and grounded.

Big name celebrities like Kim Kardashian West have also hopped on the bandwagon. West regularly endorses CBD products through her social media platforms, showing off her CBD-themed parties and meditation sessions to her 150 million+ followers. In a recent interview with People, she talked about how CBD helps her stay relaxed and focused and how her use of CBD gummies has helped regulate her sleep.⁹ Businesswoman and lifestyle expert Martha Stewart has also become a strong CBD advocate. In March 2019, she announced her new partnership with Canopy Growth, through which she aims to produce a new line of CBD lifestyle products for consumers and their pets.10 The CBD hype only continues to grow; however, company and consumer claims all lack one important detail: empirical evidence. Since CBD is marketed as a nutraceutical rather than a pharmaceutical product, it is not subject to regulated randomized-controlled clinical trials. Without such assessments there is no way to determine whether the effects of such products are due to CBD or placebo. In his interview with The Guardian, Dr. McGuire also notes that during the psychosis and epilepsy trials, patients were given about 1,000 to 2,000 mg of pure CBD tablets each day for a certain number of weeks.6 In comparison, a single CBD-infused coffee or pastry may only contain 5 mg of the compound. Thus, individuals must also consider how much of that compound is actually metabolized by their body. “Of that 5 mg, you might absorb 1 mg or less”, says Dr. McGuire. “A lot of what people may be taking in good faith may [have] absolutely no effect at all, other than a placebo effect”.6

Another concern with the current trend is that consumers may try an advertised CBD product and find that it does not have any effect. Or perhaps they experience side-effects from other ingredients in the mixture. Dr. McGuire worries this confusion may lead consumers to believe that CBD has no health benefits at all. In the long-run, these misconceptions could “damage the therapeutic potential of what could be a very useful new medicine”, Dr. McGuire explains.6

So, what is the bottom line? Clinical trials assessing the treatment potential of CBD show promising results in the area of neurological disorders and mental illness,

although further investigation is warranted for more conclusive evidence. However, the expansion of CBD into mainstream markets has given rise to products with unreliable and unmeasured health effects. Moreover, viral marketing fueled by health enthusiasts and social media support has propagated exaggerated and sometimes false claims about the effects of CBD-based products. Thus, many ill-informed consumers may be indulging in products that produce little to no health benefits at all. Overall, conflicting consumer experiences may serve to damage the therapeutic potential of CBD, which is still being clinically investigated.

In order to mitigate the spread of false information and provide consumers with a more educated background on their product purchases, the CBD market requires urgent regulation. Setting standards for CBD product purity and dosing would help ensure safety and efficacy, clarify associated risks and benefits, and streamline processes for labelling and marketing. Most importantly, CBD regulation would allow us to hold companies accountable for the promises they make to their consumers.

References

1. Mandolini GM, Lazzaretti M, Pigoni A, et al. Pharmacological properties of cannabidiol in the treatment of psychiatric disorders: a critical overview. Epidemiology and psychiatric sciences. 2018

Aug;27(4):327-35. 2. Busby M. Billy Caldwell licensed for cannabis oil use in Northern

Ireland. The Guardian [Interenet]. 2018 [cited 2019 Nov 3]. Available from: https://www.theguardian.com/society/2018/jul/05/billy-caldwe ll-heads-home-amid-doubts-over-cannabis-oil-access-northern-irleand-medication-epilepsy 3. Devinsky O, Cross JH, Laux L, et al. Trial of cannabidiol for drug-resistant seizures in the Dravet syndrome. New England Journal of

Medicine. 2017 May 25;376(21):2011-20. 4. Devinsky O, Patel AD, Cross JH, et al. Effect of cannabidiol on drop seizures in the Lennox Gastaut syndrome. New England Journal of

Medicine. 2018 May 17;378(20):1888-97. 5. McGuire P, Robson P, Cubala WJ, et al. Cannabidiol (CBD) as an adjunctive therapy in schizophrenia: a multicenter randomized controlled trial. American Journal of Psychiatry. 2017 Dec 15;175(3):225-31. 6. Lewis T. CBD: a marijuana miracle or just another health fad?. The

Guardian [Internet]. 2019 [cited 2019 Nov 3]. Available from: https://www.theguardian.com/society/2019/may/05/cbd-a-marijuana-miracle-or-another-health-fad-cannabidiol-anxiety-epilepsy 7. CBD worth $22 billion by 2022? That’s crazy, right? [Internet]. Brightfield Group. 2018 [cited 2019 Nov 3]. Available from: https://www. brightfieldgroup.com/post/cbd-worth-22-billion-by-2022 8. Scriver A. Meet Danielle Blair of Canada’s First CBD Boutique Calyx

Wellness. Edit Seven [Internet]. 2018 [cited 2019 Nov 3]. Available from: https://editseven.ca/danielle-blair-canada-cbd-boutique-calyx-wellness/ 9. Frey K. Kim Kardashian Uses CBD to Help Her Fall Asleep, Says

She Wouldn’t Take ‘Xanax or Ambien Again’. People [Internet]. 2019 [cited 2019 Nov 3]. Available from: https://people.com/style/kim-kardashian-uses-cbd-for-sleep/ 10. Owram K. Martha Stewart Developing Cannabis Pet Care, Cosmetics and Food. Bloomberg [Internet]. 2019 [cited 2019Nov3]. Available from: https://www.bloomberg.com/news/articles/2019-06-18/martha-stewart-developing-cannabis-pet-care-cosmetics-and-food

By Serina Cheung W hile the 2010s will be known as the rise of the smartphone, the 2020s are poised as the rise of “wearables”. Electronic devices that consumers can wear, such as smartwatches, are considered “wearable technology”. The advancement of smartphones has allowed for technology to be intricately woven into many aspects of our daily lives. From asking Siri the weather to tracking our steps, mobile technology is a powerful tool to make everyday tasks easier. In recent years, wearable technology has found its place in society with a particular focus on health and fitness. Consumers are becoming increasingly health conscious with the desire to take ownership of their health. According to Accenture, the use of wearable technology in the U.S. jumped from 9% in 2014 to 33% in 2019.1 As the popularity of wearables surge, the 2020s look promising for the rise of wearable technology.

The first wearable technology to achieve mainstream success was the Fitbit, a simple wristband to track one’s steps throughout the day. Fitness smartwatches have now evolved into multi-functional tools that can track heart rate and detect falls. As of 2018, Apple leads the wearables market with the Apple Watch.2 In the age of big data, the Apple Watch allows an unprecedented amount of data to be collected in real time in an accurate and non-invasive manner. Apple has partnered with top academic medical institutions to launch studies relating to women’s, cardiovascular, and hearing health.3 This innovative approach to data collection allows research institutions to take advantage of the prevalent use of wearables. With each iteration of the Apple Watch becoming more and more health and fitness focused, Apple is inevitably tapping into the vast market for wearables. The massive success of the Apple Watch has not gone unnoticed, as Google recently acquired Fitbit as their venture into the wearables market.4

Smartwatches dominate the wearables market, however, there has also been an emergence of experimental health-focused wearables with promising applications: digital temperature sensors to detect abnormal circadian temperature patterns in breast tissue. This data is submitted to healthcare providers to detect early signs of breast cancer.5

▶Microsoft developed the Emma Watch, which uses small motors producing rhythmic vibrations to compensate for hand tremors. This technology is beneficial to those suffering from movement disorders such as Parkinson’s disease.6

▶The Philips wearable biosensor is a medical-grade device that discretely and wirelessly fits on the patient’s chest. It monitors key vital signs such as heart rate and respiratory rate, allowing physicians to continuously monitor patients’ health and be notified when intervention is needed.7

As new wearable technology makes accurate real-time monitoring and data collection easier, several promising applications for the future of the healthcare industry emerge. The remote collection of large amounts of health data allows for the establishment of patterns to train machine learning models. Wearables

may have the ability to predict potential health problems before they fully manifest, allowing for early physician intervention and preventative measures. One of the most attractive features of wearables is the ability to collect physiological data in real time. The current routine of patients having their vitals taken at the doctor’s office represents a very narrow snapshot of a person’s physiology. Inferences can be made retroactively if these snapshots of a patient’s vitals are taken every few weeks, months, or years. However, frequent measurements may burden the healthcare system. Accurate and real-time measurements supplied by wearables produces denser datasets allowing for improved understanding of disease variability as well as characterisation of intra- and interpatient variability.

Real-time collection of data is also very useful for clinical and drug development trials. Most trials require patients to complete questionnaires at physical locations. However, if patients could electronically complete questionnaires using their wearables, this would improve compliance and timely collection of data, as well as reducing administrative burden.9 However, it is important to note that different modes of questionnaire administration, such as telephone-based, electronic, or paper-based self-report, introduces biases in the responses. Some of these biases include recall bias and social desirability bias and can have important implications for the validity of results. 13 Physiological data collected during early stage clinical trials may identify early safety concerns allowing dosing adjustments to be quickly made. Towards the end of clinical development, several self-reported measures are made to identify adverse effects. Perhaps wearables could provide objective biomarker measurements of traditionally subjective, self-reported attributes such as pain, fatigue, and nausea.

Although the promising applications of medical-grade wearable devices in the healthcare system have garnered lots of attention, many challenges present themselves before wide mainstream adoption. For example, a recent study in France used wearables to remotely track and analyze patients with chronic conditions in real time. This study evaluated patients’ perception of the use of wearables and artificial intelligence (AI) in healthcare. Interestingly, only 50% of patients felt that the use of digital tools was beneficial, while 11% considered it a danger. There was distrust in using AI to help physicians predict outcomes and many felt that any decisions should remain a human task. 8

Those who work on research and development in the pharmaceutical side may not be familiar with engineering devices. Conversely, the engineers working on the devices may not be familiar with the drug development process. The gap between the two industries may slow the progression of consumer friendly, health wearables. Notable non-medical grade wearables that have reached mainstream adoption include the Apple Watch and Fitbit. However, the Apple Watch is a consumer-grade, as opposed to a medicalgrade wearable. Consumer-grade devices are FDA cleared, as opposed to FDA approved. FDA clearance deems a product to be substantially similar to another marketed device. However, FDA approval requires a more rigorous review. In other words, while the Apple Watch can provide some insight to one’s vitals such as heart rate, it is not meant to replace a trip to the doctor’s office.

The electronic collection of health data also raises concerns of privacy. More than one third of Canadians use health or fitness related applications on their phone, smart watch or tablet. 11 Canada is lagging in defining the governance of health data collection by medical devices and consumer-grade wearables. 12 However, in the US, consumer-grade and medical devices are under different sets of regulations. Data obtained by medical devices require patient consent for collection and sharing. However, the data obtained by consumer-grade devices such as the Fitbit can be shared in a deidentified manner to third parties. 9 Health data is worth billions of dollars to pharmaceutical companies. As such, companies need to attract consumers to consent to data collection to be sold to third parties. Technology companies need to be transparent with the type of data being collected and the option to opt out of third-party access to data. Currently, targeted marketing ads are becoming increasingly specific and personalized. Health data is another facet that marketing companies are using to further refine and reach their target audience.

Today, the idea of a smartwatch having the capabilities of a full-scale electrocardiogram is difficult to imagine. However, as these consumer-grade and medical-grade wearable technologies mature, remote patient monitoring using wearables alone may become a very real possibility. The potential of wearables has inevitably caught the attention of tech giants and pharma companies. With some of the world’s largest companies backing the R&D of wearables, a future of wearables reaching mainstream usage may be even closer than we thought.

References 1. Accenture. Accenture Study Finds Growing Demand for Digital

Health Services Revolutionizing Delivery Models: Patients, Do [Internet]. Newsroom. Accenture; 2018 [cited 2019Nov7]. Available from: https://newsroom.accenture.com/news/accenture-studyfinds-growing-demand-for-digital-health-services-revolutionizingdelivery-models-patients-doctors-machines.htm. 2. Perez S. IDC: Apple led wearables market in 2018, with 46.2M of the total 172.2M devices shipped [Internet]. TechCrunch. TechCrunch; 2019 [cited 2019Nov7]. Available from: https:// techcrunch.com/2019/03/05/idc-apple-led-wearables-market-in2018-with-46-2m-of-the-total-172-2m-devices-shipped/. 3. Apple. Apple announces three groundbreaking health studies [Internet]. Apple Newsroom. 2019 [cited 2019Nov7]. Available from: https://www.apple.com/ca/newsroom/2019/09/appleannounces-three-groundbreaking-health-studies/ 4. Fitbit. Fitbit to Be Acquired by Google [Internet]. Press Release

Details. 2019 [cited 2019 Nov7]. Available from: https://investor.

Fitbit.com/press/press-releases/default.aspx 5. Cyrcadia Health. Core Technology [Internet]. Cyrcadia Health. [cited 2019Nov7]. Available from: http://cyrcadiahealth.com/ core-technology/ 6. Microsoft. Project Emma [Internet]. Microsoft Research. 2017 [cited 2019Nov7]. Available from: https://www.microsoft.com/ en-us/research/project/project-emma/ 7. Philips. Wireless Wearable Biosensor for Vital Signs Monitoring:

Philips Healthcare [Internet]. Philips. [cited 2019Nov7]. Available from: https://www.usa.philips.com/healthcare/clinical-solutions/ early-warning-scoring/wireless-biosensor 8. Tran V-T, Riveros C, Ravaud P. Patients’ views of wearable devices and AI in healthcare: findings from the ComPaRe e-cohort. npj Digital Medicine [Internet]. 2019Jun14;2(1). Available from: https:// www.nature.com/articles/s41746-019-0132-y 9. Izmailova ES, Wagner JA, Perakslis ED. Wearable Devices in

Clinical Trials: Hype and Hypothesis. Clinical Pharmacology & Therapeutics [Internet]. 2018Apr2;104(1):42–52. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6032822/ 10. Center for Devices and Radiological Health. Consumers (Medical

Devices) [Internet]. U.S. Food and Drug Administration. FDA; [cited 2019Nov25]. Available from: https://www.fda.gov/ medical-devices/resources-you-medical-devices/consumersmedical-devices#What_is_the_difference_between_Cleared_and_

Approved_ 11. PricewaterhouseCoopers. PwC Canada’s Consumer insights survey:

The experience is pertinent to Canadian consumers [Internet]. PwC. 2019 [cited 2019Nov25]. Available from: https://www.pwc. com/ca/en/media/release/canada-consumer-insights-survey.html 12. Canada H. Government of Canada [Internet]. Canada.ca.

Government of Canada; 2018 [cited 2019Nov25]. Available from: https://www.canada.ca/en/health-canada/services/drugs-healthproducts/medical-devices/activities/announcements/notice-digitalhealth-technologies.html 13. Bowling A. Mode of questionnaire administration can have serious effects on data quality. Journal of Public Health. 2005May3;27(3):281–91.

Monosodium glutamate (MSG) is a powerful flavour enhancer that has been a staple in cooking for decades. However, if you have spent any amount of time in a Western country, you are probably aware of the negative reputation of MSG. In fact, many of you may actively avoid MSG after hearing about the negative effects of using the mysterious powder to transform any food from dull to delicious. A deeper dive into the history of MSG reveals that fears are based less in science and more around racialized attitudes that developed after mass immigration to America. By Jason Lo Hog Tian

MSG is the salt of glutamic acid, an abundant and naturally occurring amino acid, and was first discovered in 1908 by chemist Ikeda Kikunae in Japan. MSG was isolated from sea kelp-which gives it the signature umami flavour, meaning “tasty” in Japanese. The product was initially brought to market in Japan under the brand name Ajinomoto, meaning “essence of taste”. It quickly spread around the world, ending up in restaurants throughout the United States by the 1930’s and becoming an integral food staple in the American war effort.1 However, following its initial rise to popularity, the flavour enhancer would soon come under fire due to a phenomenon that remains prevalent to this day—consumer fear. In the 1960’s, consumer trust in industry products collapsed and fear around the dangers of chemicals such as pesticides, additives, and sweeteners rose to an alltime high. MSG would soon be added to the quickly growing “do not use” list after a letter published in the New England Journal of Medicine in 1968 by Dr. Robert Ho Man Kwok describing what he called “Chinese Restaurant Syndrome” (CRS)

Vintage MSG ad from Ajinomoto kabushiki gaisha shashi [Company History of Ajinomoto Incorporated] (Ajinomoto kabushiki gaisha, 1971), volume 1

after eating at a Chinese restaurant. Symptoms included numbness in the neck and arms, weakness, and heart palpitations.2 The letter resonated with readers and soon there were countless responses flooding in from individuals claiming to have experienced similar symptoms following the consumption of Chinese food. Subsequent scientific studies appeared shortly after this initial finding that “confirmed” the role of MSG in the development of CRS.3 One such study appeared in 1977 from Harvard Medical School which claimed that 25% of people experienced CRS. By this time, the evidence against MSG was damning and public opinion of the flavour enhancer had turned sour.⁴

Despite the growing evidence of the negative impacts of MSG, many scientists remained skeptical and upon further investigation, the seemingly ironclad evidence started to unravel. The first study to demonstrate the effect of MSG using a variety of delivery methods was not blinded and had a sample size of only six.5 The study conducted at Harvard included leading questions such as “Do you think you get Chinese restaurant syndrome?” and listed the potential symptoms, creating recall bias.4 Another study conducted on individuals claiming MSG sensitivity found that when given more than 2.5 grams of MSG, participants began to experience headache and flushing.6 However, this is a

rather large dose—equivalent to about 200 grams of Parmesan cheese—and was given on an empty stomach, making the scenario rather unrealistic. So, while there are many studies condemning the use of MSG, there are clearly some holes in the narrative and more rigorous evaluation was required.

In 2000, a combined team of Boston University, Harvard University, Northwestern University, and UCLA scientists conducted a double-blind, placebo-controlled study aimed at understanding the true nature of MSG and its side effects. The study recruited individuals with a self-proclaimed MSG hypersensitivity and administered either MSG or a placebo dissolved in a drink. Subjects were instructed to fast for 8 hours and were given a breakfast after consuming the drink.7 Throughout all research sites, there were no reproducible effects of MSG exposure—individuals reporting MSG sensitivity could not tell when they had MSG or the placebo.

While it is plausible that MSG could cause adverse reactions at high doses and with certain delivery methods, there is no evidence to date supporting the idea of MSG causing CRS, especially when used under reasonably normal conditions. The U.S. Food and Drug Administration (FDA) has classified MSG as generally recognized as safe (GRAS) since 1958, and despite the overwhelming negative public opinion about the compound, the FDA has never changed its position.8 However, while the scientific community and governmental organizations have come to a consensus that MSG is not harmful, the general public has been slower to change their opinion. Figure 1 shows the results of a survey conducted in 2018 by the International Food Information Council (IFIC), an industry-funded non-profit organization. The survey shows that over 40% of U.S. consumers still actively avoid MSG, demonstrating that MSG is still a greatly feared product, right behind artificial additives, preservatives, sodium, and sugars.⁹ With science defending the effects of MSG, why is the general public maintaining such a strong stance? hypersensitivity. The same survey from the IFIC shows that consumers no longer trust traditional authorities regarding nutrition and safety, choosing to rely more on personal experience, anecdotes from friends or family, and health blogs.9 Food companies now proudly place “No MSG Added” stickers on their products to hold on to their share of the market which further exacerbates the stigma against MSG. Understanding the reason behind the unmoving public opinion may require a deep dive into the origins of CRS and where the MSG aversion came from—stigmatizing attitudes towards Asian immigrants.

If it was the MSG causing CRS, why were symptoms appearing only after eating Chinese food? MSG has been used for decades in Asia and even in Western cuisine following World War II, yet CRS reports remained isolated to Chinese food specifically. The initial popularization of CRS came at a time of high Chinese immigration rates in the U.S., and Americans were concerned about “exotic, bizarre, and excessive practices” associated with Chinese culture.1⁰ When news broke about a sickness coming from Chinese restaurants, people did not question its plausibility and their deep seeded suspicions about Chinese practices were confirmed. Scientists and laypeople alike were blinded by the narrative of a decidedly Chinese illness caused by MSG and failed to explore why other MSG products didn’t show the same effects. While racist laws barring Chinese immigration to America were removed over 50 years ago, remnants of old stigmatizing attitudes may persist and will likely take more time to completely disappear.

If any of you have actively avoided MSG, you may feel like you have been “fooled” by this misinformation. However, negative attitudes towards MSG have been so pervasive in culture and media that it is hard not to internalize some of those beliefs. Overall, this is a lesson to remain ever skeptical. The claims around CRS seemed credible – studies “confirming” the syndrome were conducted at prestigious institutions and published in influential journals, media sources relentlessly reinforced the idea, and most of the public were adamant in their belief. Like with any form of misinformation, a large part of changing public opinion is raising awareness around the knowledge gap and educating the public about best practices. We, as citizens of the world, must always question where ideas come from and the rationality behind those claims, even if it seems like the entire world is behind it. While CRS may have its roots in racial prejudice, the fear of MSG grew into a health-related consumer fear until it permeated Western culture—something we still feel today over 50 years later.

0 10 20 30 40 50 60 Consumers still avoid MSG, 50 years later MSG still ranks among the top ingredients that Americans try not to eat, behind artificial additives, sodium and added sugars

Added sugars Preservatives

MSG Caffeine

GMOs Gluten Sodium Artificial colours Artificial flavours

Source: International Food Information Council

References

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Practitioners. 2006;18(10):482-6. 4. Reif-Lehrer L. A questionnaire study of the prevalence of Chinese restaurant syndrome. Federation proceedings. 1977;36(5):1617. 5. Schaumburg HH, Byck R, Gerstl R, Mashman JH. Monosodium

L-glutamate: its pharmacology and role in the Chinese restaurant syndrome. Science. 1969;163(3869):826-8. 6. Yang WH, Drouin MA, Herbert M, Mao Y, Karsh J. The monosodium glutamate symptom complex: assessment in a double-blind, placebo-controlled, randomized study. Journal of Allergy and

Clinical Immunology. 1997;99(6):757-62. 7. Geha RS, Beiser A, Ren C, Patterson R, Greenberger PA, Grammer

LC, et al. Multicenter, double-blind, placebo-controlled, multiple-challenge evaluation of reported reactions to monosodium glutamate. Journal of allergy and clinical immunology. 2000;106(5):973-80. 8. Meadows M. MSG: a common flavor enhancer. FDA Consumer magazine. 2003. 9. Dewey C. Why Americans still avoid MSG, even though its ‘health effects’ have been debunked. The Washington Post. 2018. 10. Mosby I. ‘That Won-Ton Soup Headache’: The Chinese Restaurant

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