Endometriosis is an interesting disease
144 comments
·June 13, 2025kjellsbells
giantg2
"I don't know whether this is a result of..."
The cause is pretty easy. Patients aren't treated like mysteries, they're treated like BAU Jira tickets - just get it done so you're on to the next one. The system is built to handle the 90%. If you fall into that other 10%, it won't work well for you. If you have provider companies and insurances pressing you to hit some metric, that's what you have to do. If you are concerned about malpractice, then you have to just read from the Epic system. No surprise we're in this situation.
KaoruAoiShiho
Yep this is something that only AI can solve. Same situation applies to education, sales, HR. Human powered bureaucracies and systems suck.
dayofthedaleks
Any AI will most certainly reflect the biases of the bureaucracies responsible for their creation.
renewiltord
Amusingly this is why people say LLMs will beat doctors. It’s because the 90% of cases is so easy that a motivated guy with Google can get there and a smart NP can get there too.
It isn’t that it’s easy to do all a doctor does. But their training and knowledge shines in the 99th percentile case except they never exercise it there so you can usually get there with Google.
“Oh but an LLM will guess the common case and never think of the rare!”
Yeah but so will a doctor given 10 minutes on it. They’re not exactly going to House MD you. You’re gonna die.
placardloop
My significant other is going through this situation, and in my experience it seems as though most doctors just simply don’t care to actually find a diagnosis (or at least, don’t have the time or motivation to care), combined with a hefty dose of “that’s not my job”. My SO has been to specialist after specialist who spends a grand total of 2 minutes listening to the symptoms, followed by “well let’s do some blood tests and see what they say” (ignoring that the last 5 doctors already did blood tests). And then when the blood tests come back with nothing obvious, the doctor just throws up their hands and says “well I don’t know what to do, you should go see <other specialist>”.
The reason the “family member or friend who knows someone who can recommend a doctor” seems to work well, in my experience, is because that doctor then has some motivation to actually care, as the patient is connected to someone they already know and care about.
Our medical system financially incentivizes doctors to see as many patients as possible, but doesn’t financially incentivize actually making them better. For that, the system just hopes that doctors will care, without giving them the room to do so.
epistasis
Another way to look at it instead of "they don't care" is "they have nothing they can offer."
We have progressed fantastically on the common medical conditions, but once you get into more rare stuff it gets a lot harder. Doctors have huge breadth of knowledge, but the sum of human medical knowledge could never fit into a human brain, even within a specialty, and even then there's so much we are not even close to understanding or knowing.
And for rarer stuff that is just getting discovered and learned about, there will only be a few specialists who are the ones figuring it out. That's why you go to lots of doctors that offer nothing, then a hint directs you to the doctors that are in the cutting edge of expanding knowledge.
Even if we financially incentivized each and every doctor to spend hours or days trying to find out what's going on with a patient that the doctor can't help with their current knowledge, it's quite likely that doctor could never help on the basis of a single patient. Medicine advances through discovery in groups of people and transferring knowledge from the results of one patient to others, incrementally. A single patient is far less likely to lead to advancement than a doctor having a group of people with similar symptoms.
The financial incentive for this discovery comes from research hospitals that collect these difficult cases, and obtain federal research grants from the National Institute of Health that allows them to do research and publish papers and share the knowledge. The proposed budget for the US drastically slashes this, greatly reducing our ability to advance medicine. And in advance of the budget cuts, the NIH is in violation of current contracts stopping payment, resulting in massive waste as research dies on the vine.
So what I'm trying to say is that the logistics of advancing medicine require grouping patients, and the place where that happens is at research hospitals, not at the local community doctor for everyday care. And our society is choosing, consciously or unconsciously, to drastically reduce access to that type of care.
dapper_bison17
I agree that it seems we can't rely on the medical system specifically in the case of Endometriosis.
One of my best friends faced a similar struggle and took things into her own hands. Now she's been able to overcome most endo symptoms and has started her own program where she teaches other women how to do the same.
I'd love to connect you/your wife to her if you want!
Henchman21
What our "system" seems to actually incentivize is keeping people chronically ill so that they're forced to continually pay for their non-treatment.
It's hard not to be incredibly cynical in the face of things like this. Way more than once have I thought "this is a cruel and unusual punishment" -- wait aren't those prohibited?? Oh right we get around that by making cruelty usual.
margalabargala
I see this view sometimes and it really annoys me.
The number of doctors and nurses that attempt to keep people chronically ill rather than curing them if possible, is essentially zero. People get into that field frequently because they actually care, and people that actually care are the most likely to not follow a vague profit incentive that actively hurts people.
Similarly, most medical researchers would love to cure diseases, and actively seek out jobs where they do so and will object if asked to suppress curative research.
To the extent that what you describe exists, it is limited to MBA people at insurance companies and big pharma determining what gets funded for research. While exceptions always exist, the incidence of that attitude among the people actually doing the work is very close to nil.
liquidise
I feel this is more a societal failing than a medical one. Most people don’t want to take better care of themselves: eating better, portion control, more regular exercise, etc. Too hard.
People want a pill to solve the ailments they have.
tekla
People want medication to solve their problems, not actually try and solve things without paying money for it
GrantMoyer
I think it's probably just really hard to diagnose uncommon diseases in people (although endometriosis in particular may be fairly common). I have trouble diagnosing some bugs in software at my job; I imagine it's much harder to diagnose issues in a human body.
Spooky23
Frontline medicine is all about “just do x” hacks to try to move quicker. We turn people into a fault tree, and enforce that with EMR and audit/review you create a bias to focus on the 80/20 approach. Essentially turning medicine into a helpdesk.
A family member ran into this with a brain tumor, which for a patient presenting with a headache is a 1% likelihood. Slightly elevated blood pressure was the focus in that case. Persistence and a subtle symptom changed triggered the CT scan that ultimately led to the diagnosis about 8 weeks later. Unfortunately with melanoma, 8 weeks is a long time.
Ultimately there’s no right answer. 99% of people with headaches have high blood pressure or other “normal” causes. Sending 1,000 people to CT to identify 5 tumors will cause 50 other complications.
Think of doctors like a helpdesk in a big company. Open a ticket, but work your network to get someone who isn’t dumb to think about it. If you’re too poor or don’t have friends and advocates, your outcome will be no mas.
margalabargala
> Sending 1,000 people to CT to identify 5 tumors will cause 50 other complications.
This is something frequently missing from discussions like this.
Something that has a fairly small per-patient risk like a CT scan, causes far more pain than reduced missed diagnoses would solve if applied across the whole population.
Spooky23
Not only that, but you have red herrings. Going down the rabbit hole chasing random anomalies doesn’t solve the patients problem either!
ozim
"Now it is a strange thing, but things that are good to have and days that are good to spend are soon told about, and not much to listen to; while things that are uncomfortable, palpitating, and even gruesome, may make a good tale, and take a deal of telling anyway."
“Happy families are all alike; every unhappy family is unhappy in its own way".
To sum it up, not much to write about ones that went to primary care and were handled properly.
smeej
I just had an "on this day" reminder pop up that told me I've been searching for the answers to two relatively common problems for twelve years with no progress, unless you count ruling out the same damn primary suspects over and over and over. I get migraines at the same time of month every month, and I have chronic pain in my heel and 2nd metatarsal--and no, it's not plantar fasciitis.
Every couple of years, I get renewed energy to try the search again. It lasts for a year or two before I run out of steam, give up, and decide to live with it, because I'm easily 6 figures into trying to be able to walk without pain and not be laid out with a headache every month.
100% of doctors started with telling me the problem was my weight. I lost 50 lbs and all my symptoms got worse, so they pivoted to telling me it's psychogenic. All of them. But I've been through all the recommended types of psych treatment too, and a few experimental ones besides.
In point of fact, I cannot convince anybody who might know to care enough to find out, and it seems unlikely I ever will. There doesn't seem to be any good reason I should be stuck with these pains, but there are only so many times I'm willing to try the same things, expecting different results, because this doctor thinks all the other ones must have been too stupid to rule out the obvious causes.
dapper_bison17
That really sucks. It sucks even more that your situation is common to many many women.
One of my best friends faced a similar struggle and took things into her own hands.
Through a lot of trial and error and a lot of studying, she's been able to overcome most endo symptoms and has started her own program where she teaches other women how to do the same.
I'd love to connect you to her if you want!
She's already helped around 30 women with similar struggles. Some have managed to get rid of bloating in a matter of weeks, one even has Crohn's disease and for the first time in 14 years woke up without any stomach pain.
My friend's program isn't a "magic pill" obviously but it sounds like it's worth a shot.
Let me know :)
itronitron
I recommend taking probiotic Bacilis Subtilis gummies if you feel a migraine starting, I don't know why it works but it does (and I first heard about Bacilis Subtilis hear on HN.)
wbl
Migraine drugs have improved incredibly in the last few years. As a fellow sufferer I recommend you ask about them: given the same time of month you can likely preempt them entirely. I hope you get some answers!
scythe
Popular understanding, particularly in the United States, is a little behind the scientific opinion on the subject. Most women I've talked to are still under the impression that endometriosis can only be diagnosed by laparoscopy. But there have been improvements in the use of contrast MRI for diagnosis, and as of 2022 the guidelines in Europe recommend MRI as the first option.
https://pmc.ncbi.nlm.nih.gov/articles/PMC9732073/
However, the protocol isn't perfect, and there is probably still room to develop better contrast agents and MR sequences.
>some kind of ignorance of womens' conditions
Some things are just hard. The treatments for benign prostatic hyperplasia suck too. There is no effective reversible pharmaceutical male birth control. Et cetera.
joshuajooste05
My girlfriend has endometriosis, I hadn't really read much about it until now, thank you for writing!
I think this is a story too common in women's healthcare.
It's often massively underfunded and underesearched, another symptom of the fact our society had not let women into STEM/politics for decades, and continues to erect barriers to encourage them not too.
I like the fact you spelled out the incentives for PhDs to do so at the end ;). Would be great!
catigula
>and continues to erect barriers to encourage them not too
Funny, my experience is the absolute opposite of this claim.
Also, I could be wrong but I'm pretty sure breast cancer is the single most well-funded areas of cancer research.
jwrallie
One interesting thing I observed by being trilingual is that different countries’ medical systems will give different and sometimes contradictory instructions when you Google for some medical information.
One of this is sex during menstruation. I was instructed that it was not a problem but in Japan they specifically instruct that it is discouraged because there might be a link with Endometriosis.
If you try to Google if sex in menstruation can lead to infertility you are going to find little information in English, but you are going to find many hits in Japanese.
317070
There are so many more of these. A common one is everything to do with babies.
* In the UK you should not start solids before 6 months, in France you can start at 3, and should at 4.
* Baby bed room temperature: in the UK 16 degrees Celsius, France 19 degrees, in the nordics you should have them sleep outside while I've been told that in Hungary 25 degrees is considered optimal.
Don't underestimate how much of health science is embedded folklore knowledge by people who thought they managed to extract signal from noise with a lot of confounders, especially if the patient is not sick or cannot express their subjective experience.
porphyra
Also, in the US people have a deathly fear of bedsharing with the baby due to concerns about sudden infant death syndrome (SIDS) and yet bedsharing is common in places like Japan while they also have a much lower infant mortality rate. Apparently, newborns just sleep very poorly lying on their backs alone in cold, hard cribs rather than nuzzling against their moms' breasts. As a result, the common advice in the US has not only led to skyrocketing cases of postpartum depression, but also delayed milestones such as head lifting, plus more cases of plagiocephaly and torticollis.
(that said, as a new dad, I'm also deathly afraid of SIDS so I still stuck by the American recommendations, sleep be darned)
rescripting
Some of that fear isn’t necessarily unfounded. In America the people are larger and the beds are softer. This creates a larger, deeper divot around the adult for the baby to roll in to and suffocate.
Enginerrrd
Most of the American parents I know practiced bed-sharing including myself. But we would also answer "no" when asked about at the doctor's office because that's the "right" answer. So... I am skeptical about any negative statistics on bedsharing. We're not obese and don't drink or do drugs. That probably mitigates a huge amount of associated risk.
throwaway173738
If you ask around among other parents you’re going to find that bed sharing is a lot more common than the medical community wants it to be. We had a lot of reasons for doing it and so did many of our friends.
treyd
If I recall correctly, there was some recent research connecting the cholinergic system to SIDS, pointing at possible changes in practices to reduce the risk.
scythe
I've come to think the American norm is something of a self-fulfilling prophecy. Bedsharing becomes dangerous mostly when the parents fall asleep intoxicated. You might have noticed that you're much more likely to wake up with your arm partially numb if you pass out drunk than if you go to sleep sober. But because bed sharing is discouraged, it's mostly less responsible parents who do it, which creates a stronger apparent correlation with infant suffocation.
kqr
My favourites are
- How much alcohol can a pregnant person drink? (Not too much, obviously, but is a glass of wine a couple of different days in the third trimester okay? Probably, but it varies a lot deoending on which country you're in.)
- When can children start eating green leaves? (I don't know, but even different counties in Sweden have different guidelines on that one.)
- Should infants sleep on their tummy or back? (Definitely on their back. There is no argument there. But when I was an infant -- which is not that long ago, parents were advised otherwise.)
margalabargala
> How much alcohol can a pregnant person drink? (Not too much, obviously, but is a glass of wine a couple of different days in the third trimester okay? Probably, but it varies a lot deoending on which country you're in.)
It's important to differentiate a low individual risk for you, vs what that means to a whole population.
You will easily find someone willing to say "oh I had two glasses of wine a week while pregnant and my kid was fine".
If everyone started drinking 2 glasses of wine a week in the third trimester, FAS rates will increase, and mean IQ score will dip. Will they dip by a lot? Probably not, but definitely not zero. So of course anyone in a position to make a society-wide recommendation, recommends "no alcohol".
Individual parents may look at data and say, that's a risk they're willing to take.
freddie_mercury
> But when I was an infant -- which is not that long ago, parents were advised otherwise.
So...research was done and people learned they were wrong?
I'm not quite following what you think the takeaway was here?
The "Back to Sleep" campaigns saw something like a 50% decrease in infant mortality within 12 months in the UK. It isn't really comparable to "fad diet of the year" medical advice.
spockz
For sleeping on their back. Our youngest daughter would not sleep on her back. She still sleeps on her tummy with arms folded under her. The only way she sleeps otherwise is in the car seat when properly exhausted. Put her to bed and she will turn around and fall asleep. So what does medicine say then?
maccard
> But when I was an infant -- which is not that long ago, parents were advised otherwise
Medicine is wild. Lots of things that were taken as gospel even 15 years ago have been completely flipped on their head. The NHS massively changed their advice last year on asthma treatment and it’s basically the opposite of what they said before. We’ve seen the same with musculoskeletal injuries, nerve injuries and just general recovery.
freddie_mercury
The temperature thing is one I always wonder about.
The WHO claims the ideal overnight temperature for sleeping is 18 degree (C). I lived in Vietnam for a decade and to a rough approximation 0% of the population ever experiences 18 degrees overnight for sleeping. And I imagine it's not too different in much of Thailand, Indonesia, India, etc.
I'm pretty dubious that hundreds of millions, maybe billions, are thriving in "suboptimal" overnight temperatures!
Does the African savanna regularly get down to 18c at night, such that we'd expect that to be some kind of evolutionary equilibrium that just happens to map to (northern) European and North American norms?
null
akvadrako
Humans can thrive in nonideal situations. I would say too ideal is unhealthy.
Plus the effect might be small or something easily adapted to.
gradus_ad
Well, hot places do tend to have indolent populations.
abxyz
Another example is Ureaplasma Parvum which is treated as a serious STD in parts of the world but almost never acknowledged as an STD in the U.S. and therefore almost impossible to get tested for and treated for in the U.S. There’s an entire reddit about it: https://www.reddit.com/r/Ureaplasma/
Full background: https://www.reddit.com/r/Ureaplasma/comments/qavqf1/the_urea...
andrelaszlo
An Argentinian friend of mine said you get cancer from drinking beverages that are too hot. He sent the Wikipedia page to prove it but only the Spanish version of the page had this information.
Is this another example of culturally specific health "facts" or have I just missed something?
ifwinterco
I think this is true but it's much more of an issue in LatAm countries where they drink mate through metal straws.
In european/North American countries where people normally drink out of ceramic mugs, people generally end up drinking hot drinks at a lower temperature
viciousvoxel
There's been conflicting information about this over the years. The latest research suggests that it may increase cancer risk when combined with other behaviors that themselves increase risk, but it probably has little to no effect on its own.
https://www.mskcc.org/news/burning-issue-truth-about-hot-dri...
azepoi
Heard this in France too from MD. Link between drinking too hot (over 60°C) and oesophagus cancer
SwtCyber
The "hot drinks cause cancer" thing is surprisingly legit
decimalenough
Yup, pregnancy/childbirth/rearing is particularly rife with these. Western sources suggest that eating sushi while pregnant is little short of stabbing yourself in the abdomen with a sharp knife, Japanese sources explicitly recommend sushi as a light and healthy meal. In the US giving any form of peanuts to babies is attempted murder, in Israel peanut puffs (Bamba) are among the first foods offered.
hnthrowaway121
> In the US giving any form of peanuts to babies is attempted murder, in Israel peanut puffs (Bamba) are among the first foods offered.
This is not the case, peanut puffs are a common early solid food in the US. Before that there are allergen mixes you can add to milk/formula.
All the recommendations I saw when my kid was born said early exposure to allergens is good to reduce chances of allergic reactions.
SwtCyber
Makes you realize how much of what we think is "settled science" is often just what gets repeated in a given language or culture
pcthrowaway
Do you mind sharing a promising article in Japanese which can be translated?
jwrallie
I just took the first link from a Google search that looked not to be advertisement (edit: but still kinda is)
worldsayshi
This makes me wonder how to search for content in another language? I mean most sites are almost trivially translatable by now.
OJFord
You just search in the language you're looking for?
(And if you have a country filter/hint set on your search engine of choice, you disable or change it appropriately.)
thaumasiotes
You can easily autotranslate your question into whatever language you'd like to search, go to a search engine for that language, and see what you get.
If I want to do a search for Chinese content, I go to baidu, enter a query that makes sense to me, and look for a suggested query that looks right.
Doing this is much less useful than you might think. You'll still lack the ability to interpret the search results, or the pages you click through to. It's not an issue of translating the content. You have no idea what kind of pages you've turned up, what the ones you want should look like, or how information is laid out in the foreign websites. Your habits from the English-speaking internet won't apply.
dillydogg
To help support the "retrograde menses is incomplete" discussion; I was involved in a case where a woman had a bone marrow transplant for her CML. She later developed "appendicitis" when but when the tissue sample came to the pathologist, the appendicitis was actually endometriosis. Even more, the endometriosis was XY karyotype, ie derived from the bone marrow transplant. We wrote up a case report.
NB - It is a known phenomena in bone marrow transplant recipients that the donor DNA can be taken up by host cells by unknown mechanisms, so it isn't a guarantee that the endometriosis was developed from the transplanted bone marrow.
SwtCyber
It's one thing to know, in theory, that stem cells can end up in strange places after transplantation, but to see that play out in something as enigmatic as endometriosis really underlines how little we know about the underlying mechanisms.
dillydogg
It was surprising to me when I saw the cells under the scope when I expected appendicitis! The karyotype was just for fun, but the XY testing was quite unexpected.
pcthrowaway
Indeed, very interesting! I suspect readers who enjoyed this may also enjoy this recent dive into the prostate which was shared here ~7 weeks ago: https://news.ycombinator.com/item?id=43801906 . It has a somewhat more hopeful and dare I say, happier ending
codetweep
The article sort of glosses over a major distinction regarding the surgical approach to endometriosis -- 90+% of OB/GYNs are trained to ablate (burn-to-destroy) the affected tissue, whereas more recently, a crop of surgeons have begun to specialize in excising a wide area of tissue surrounding the affected tissue. Many times, the tissue to destroy is not on the surface - it is deeply infiltrating what it has adhered to. Burning it is just like cutting grass, it'll come right back. Success rates with excisional surgery are markedly better, but not a silver bullet.
emmelaich
Considering the magic of birth and the war in the womb[0] it's amazing that the reproductive system works as well as it does.
Pregnancy relieves the symptoms but is not a cure. But surely you'd have to consider lower fertility has something to do with the increase in endometriosis.
[0] https://aeon.co/essays/why-pregnancy-is-a-biological-war-bet...
kqr
> Considering the war in the womb it's amazing that the reproductive system works as well as it does.
...or maybe it's because of that war it works as well as it does? Maybe it takes agents in opposition to evolve enough redundancies and contingency plans to get things working?
Before Mendel, at least some people hypothesised there must be some sort of "battle of the germ cell" that powered evolution, because unimportant functions -- even when they aren't actively detrimental -- tend to be forced nearly out of existence.[1] Even our bodies, miracles of cooperation, evolve to some degree under antagonism.
Thanks for referencing that article, though. I was going to but now I don't have to. Everyone should read it. Utterly fascinating.
[1]: The example that comes to mind are the femurs of whales. They are absolutely tiny. Much smaller than can reasonably explained by them being a problem for the whale itself.
fsckboy
>what actually is the clinical definition of endometriosis? Plainly put, it is when tissue that resembles the uterine lining, or endometrial-like tissue, grows outside the uterus. The tissue can implant itself in nearby tissues, like the ovaries and fallopian tubes, or even more distal organs like the bladder and bowel. ... Over time, these repeated cycles of inflammation and fibrosis may lead to permanent structural changes within the abdomen and pelvis, contributing to chronic pelvic pain and infertility.
i feel like something has been left out. why would uterine lining cells outside the uterus lead to infertility inside the uterus? from this description, I can see all sorts of things going haywire, but it was my impression that the uterine lining was scarred and otherwise rendered infertile for implantation.
setopt
> why would uterine lining cells outside the uterus lead to infertility inside the uterus?
The quoted text mentions for example the ovaries themselves, which if damaged can not release eggs, and the fallopian tubes, which if damaged can not transmit eggs from the ovaries to the uterus. These are outside the uterus.
streptomycin
The uterus is not the only thing involved in infertility. More generally, endometriosis probably affects fertility in multiple different ways, and a woman with endometriosis and fertility issues may never know what her specific problem is.
On the plus side, IVF works pretty well for many women with endometriosis. IVF patients with endo have only somewhat worse stats than other IVF patients.
SwtCyber
It's less about scarring inside the uterus, and more about chaos in the neighborhood
mlyle
You don't understand why uterine cells screwing up the fallopian tubes or ovaries would cause infertility?
cantor_S_drug
I heard about this disease through an education channel.
https://www.youtube.com/watch?v=KzA9VATcZhY
> The speaker had been experiencing symptoms like period pain, bloating, and fatigue for years, visiting many doctors without getting a proper diagnosis. When severe pain developed, a GP ordered an ultrasound but the speaker initially ignored the results, assuming it was just an ovarian cyst. However, after using the Ada AI medical diagnosis app, which asked questions about symptoms and calculated probabilities of various conditions, it suggested endometriosis - a condition the speaker had never heard of. This prompted them to return to their doctor, where the ultrasound results confirmed the AI's diagnosis of endometriosis.
twodave
Not sure if the article mentioned it (writing style was getting on my nerves about half way through), but endometriosis is also highly hereditary. My wife’s mother has 2 sisters. One sister had endometriosis and the other two had daughters (including my wife) who had it.
It has also been known to degrade egg quality, resulting in total infertility in some (including my wife and her aunt—jury is still out on the cousin).
I don’t think most reproductive surgeons think of endometriosis as untreatable. 1% rate of having some kind of complication from the surgery doesn’t sound crazy high to me. The recurrence rate I think depends pretty heavily on how pervasive the case was and how soon it was caught.
My wife was in her late 20s when she had surgery to have it cut out via laparoscopy, and it wasn’t really a big deal. She had a hysterectomy this year for other reasons, over 15 years later and had no signs of recurrence.
tptacek
The article mentions it. If you bailed before that point, you bailed just before it got really good.
SwtCyber
The comparison to cancer is honestly kind of chilling. The fact that endometriosis lesions pick up the same mutations, adapt to evade the immune system, and yet are considered "benign" is such a medical blind spot
echelon
There are probably other pluripotent cell types that do the exact same thing, but just don't get detected since very few cell types slough off with a hormonal cycle.
There are probably many more instances of this disease in men that never get triggered and discovered due to atypical hormonal levels being required.
Our bodies are weird systems.
null
I'm always struck by stories of how difficult it is to get a condition diagnosed. Endometriosis is a great example as the OP author notes.
The New York Times used to run a series of medical case studies in their magazine, and over and over again the story was essentially that the patient sought care from primary care and specialists, without success, and were generally miserable, until a miraculous event happened, like a friend's aunt knowing someone at Johns Hopkins, and that doctor having the time to think about it. The problem was incredibly evident for female patients.
I don't know whether this is a result of doctors being burned out by the system that they work in, a certain doctorial arrogance that diminishes their listening skills, over-reliance on heuristic diagnoses, some kind of ignorance of womens' conditions, or even a kind of medical misogyny. But it pushes people pretty quickly towards Dr Google and sometimes, sadly, into quackery, and that can't be a good thing.