Equalizing arthritis care for women

When hip or knee arthritis pain and disability persist despite medical treatment, doctors often recommend joint replacement surgery. But they’re more likely to recommend a surgery if the patient is male, according to the findings of a pivotal study authored by Dr. Gillian Hawker.

Women are twice as likely as men to suffer from arthritis. Yet Hawker’s highly cited study found that the “unmet need” for joint replacement surgery in Ontario – that is, the number of people with severe arthritis who could benefit from surgery – was three times higher in women.

“We needed to understand the patient, physician and health system factors that might explain this gender inequity,” says Hawker.

Inspired by Hawker’s work, Dr. Cory Borkhoff decided to focus her PhD thesis on the question of whether or not physician bias may be at least partly responsible for this inequity in care.

“I trained two standardized, undercover ‘mystery’ patients, a man and a woman with identical symptoms, and sent them into the clinics of orthopaedic surgeons,” says Borkhoff. She found that women are half as likely as men to be recommended for total joint replacement.

“It’s not conscious or intentional, but perhaps physicians don’t always see the seriousness of women’s symptoms,” says Borkhoff.

Now, with funding from the Canadian Institutes of Health Research (CIHR), Borkhoff will evaluate whether an existing patient decision aid can help to reduce gender disparity in total joint replacement surgery. To test it, she’s planning to repeat her study with clinically identical undercover mystery patients. This time, the physicians will be supported by a patient decision aid.

“We believe the patient decision aid will draw physicians’ attention to the task cues, rather than the social cues they’re receiving from patients,” says Borkhoff. “We think that this tool has the potential to neutralize unconscious stereotypes and social assumptions so that doctors see the patients in front of them.”

Borkhoff has a long road ahead. She will first recruit physicians to participate and ask them to integrate the patient decision aid into their daily practice. Only then can she send in the standardized patients.

“Dr. Borkhoff’s PhD research was the first to show, in actual clinical practice, that a person’s gender influences what treatment a physician recommends,” says Hawker.

“The next phase of her work will be an outstanding test of the efficacy of this patient decision aid to reduce gender bias in clinical practice.”


  • In 2000, Dr. Gillian Hawker published pivotal findings proving that the unmet need for knee replacements was three times higher in women
  • In 2002, Dr. Cory Borkhoff began her PhD work, with Hawker on her thesis committee
  • In 2007, Borkhoff successfully defended her thesis
  • In 2008, the Canadian Medical Association Journal published Borkhoff’s PhD thesis work
  • In 2010, Hawker was presented with the inaugural WCRI Mentorship Award
  • In 2011, Borkhoff was the recipient of the Helen Marion Walker Soroptimist Women’s Health Research Scholarship
  • In 2012, Hawker completed a CIHR-funded study examining men and women’s different information needs about joint replacement, and examining their differing communication styles with orthopaedic surgeons
  • In 2012, Borkhoff became a WCRI scientist

This is just one example of how we build research capacity by investing in the next generation of scientists.


Today, Borkhoff is a scientist at WCRI and an assistant professor in the Institute of Health Policy, Management and Evaluation at the University of Toronto

Dr. Gillian Hawker is Women’s College Hospital’s physician-in-chief of medicine, a senior scientist at WCRI, the F.M. Hill Chair in Academic Women’s Medicine, and a University of Toronto professor in the Department of Medicine and the Institute of Health Policy, Management and Evaluation.