Why Men Won't Go to the Doctor, and How to Change That (Wall Street Journal)

Dr. James Kashanian weighs in on men's reluctance to seek medical care and the increase in men's health centers in the United States

Why Men Won't Go to the Doctor, and How to Change That; Many men view health complaints as a sign of weakness. So health-care providers are looking for ways around their reluctance.

Landro, Laura.Wall Street Journal (Online); New York, N.Y. [New York, N.Y]30 Apr 2019.

Men are notoriously bad patients.

Compared with women, they avoid going to the doctor, skip more recommended screenings and practice riskier behavior. They also die about five years sooner, live with more years of bad health and have higher suicide rates. Now, with growing recognition that treating preventable causes of death and disability could close the medical gender gap, the health-care industry is mounting a new push to get men the care they need.

Hospitals are creating centers, often run by their urology departments, to provide comprehensive male-focused care, in a more welcoming environment than the traditional physician's office. And they are leveraging issues men care about the most—such as prostate conditions and sexual function—to make sure men go to the doctor in the first place. Once the men see the urologists, the doctors can talk to them about a range of health issues and push them to see other specialists.

Meanwhile, some efforts aim to get men to seek out care without going into an office at all—thus avoiding potential embarrassment—by connecting with doctors remotely.

Experts say such efforts are aimed at breaking down the cultural and social barriers that have led generations of men to view health complaints as a sign of weakness. Researchers say that men are conditioned from a young age to avoid sharing emotions, feelings or stressors. In sports competition, studies show, male athletes more often feel pressure to play through pain and injury. That may translate into ignoring pain or symptoms that may be signs of disease later in life.

"Men have connected to ideas of masculinity that say you don't talk to others about your problems, and if there is a problem you fix it yourself," says Mieke Beth Thomeer, associate professor of sociology at the University of Alabama at Birmingham.

None of this is to suggest that women don't have their own medical disadvantages. They are twice as likely to die within 30 days of a heart attack than men, with evidence suggesting they may be treated less aggressively. And some conditions that affect women have been misunderstood or played down by doctors for years, including autoimmune diseases and fibromyalgia.

But women have a far stronger record when it comes to regular care, in part because they typically segue from their pediatricians to new relationships with gynecologists who often serve as primary-care doctors.

Mount Sinai Health System in New York opened a sports-themed urology center that's a way to 'to get men into the health-care system,' says department head Ash Tewari. PHOTO: Michael Rubenstein for The Wall Street Journal

Men, however, "might not see another doctor after their pediatricians until they are in their 50s or 60s." says Steven Lamm, an internal-medicine physician and medical director of NYU Langone's Preston Robert Tisch Center for Men's Health.

Here's a look at some of the efforts that the medical establishment is using to break down men's reluctance to seek out care.

Putting the urologist in charge

At many medical centers, urologists are taking on a new role: the quarterback for broader concerns about men's health.

Men have a habit of avoiding doctor visits unless they have a problem that really hits home, like erectile dysfunction or painful urination, experts say. So, urologists have begun using those visits as a chance to look for warning signs of broader health problems and get men to arrange appointments with other specialists.

While urologists may not be trained to manage those conditions, they are learning to play a key role in identifying patients needing further evaluation and working with other specialists, says Martin Miner, a professor of medicine and urology at Brown University and co-director of the Men's Health Center at the Miriam Hospital in Providence, R.I. The American Urological Association, for instance, has developed a checklist of health concerns to help urologists better coordinate care with other providers.

"A guy could go decades without seeing a doctor, but when he is having trouble with erections or waking up three times in the night to urinate, he will seek medical attention," says urologist David Paolone, vice chair of community and regional urology at the University of Wisconsin School of Medicine and Public Health. "We need to look beyond those initial complaints at what could be leading to this, what unrecognized problems you have, and how we could be taking better care of you."

Dr. Miner says the concept of urologists addressing broader men's health began in large part with the discovery that erectile dysfunction is directly linked to heart disease. Studies have found that the condition can predict heart-disease symptoms within five years, and that it may also be a symptom of high blood pressure, diabetes, obesity and depression.

"It's a sneaky way of trying to improve overall health and cardiovascular health by motivating them about erections," says the University of Wisconsin's Dr. Paolone. But he also speaks plainly to patients: "We are looking for risk factors for your heart health, and if we don't do something, you are at risk of dying from a heart attack down the road."

Medical centers are also beginning to develop setups specifically designed to make it easy for men to make all of their appointments in one place. So if they come in to see a urologist, they don't have to make multiple appointments in multiple locations to see other specialists.

James Kashanian, assistant professor of urology and reproductive medicine at Weill Cornell Medicine in New York, estimates that close to 50% of major hospitals now have men's health centers, up from about a third identified in a 2014 study he co-wrote.

At Cleveland Clinic's Center for Men's Health, patients can schedule appointments with multiple providers, such as a cardiologist, endocrinologist, dietitian and urologist, all at the same visit.

"We want to be a one-stop shop and encourage men who might not be thinking about the risk of heart disease," says urologist Eric Klein, chair of Cleveland Clinic's urology and kidney institute.

Designing with men in mind

Mount Sinai Health System in New York recently unveiled a sports-themed center at its Midtown Manhattan urology practice, in partnership with the design nonprofit Man Cave Health. In addition to educational resources on prostate health, the waiting area has a coffee bar, TVs tuned to sports stations and memorabilia from local teams. The idea is to make men feel at ease about showing up in the first place.

"We just need to find ways to get men into the health-care system, and then we can start educating them on why they need to take as good care of themselves as they do of their cars," says Ash Tewari, a prostate-cancer surgeon and chair of Mount Sinai's urology department.

Thomas Milania Jr., 51, is a patient of Dr. Tewari's who started Man Cave Health to raise awareness of men's health issues after his own prostate-cancer treatment. He says five more Man Caves are in the works.

"From personal experience, it's kind of depressing to sit in a doctor's waiting room, especially when there is nothing to look at besides the walls," Mr. Malina says. "If we provide men with an environment that is male-friendly, it will encourage them to seek preventive care."

Of course, the definition of a male-friendly environment may vary along with the patient population. Jesse Mills, a urologist and director of UCLA Medical Center's Men's Health Clinic, says a recent remodeling with simple, streamlined furnishings aimed for a more gender-neutral design. "L.A. is a very diverse population with a large portion of people who aren't gender-conforming, and we want to make everyone comfortable," he says. "My goal is to break through the stereotype of what it means to be a man in the first place and get men the health-care services they might not even realize they need."

To put men at ease, NYU Langone's men's health center, on three floors of a Midtown office building, was designed to look more like a corporate office, with muted colors, darker woods and more conservative fabrics and patterns in the waiting room and exam areas. But its chief, Dr. Lamm, says the real appeal is the ability to schedule appointments in one location with multiple specialists, including cardiologists, physical therapists and eye doctors.

Dr. Lamm says the center is drawing in younger men who have no need for a urologist but may come in for a hernia or illness. "I will tell them, I know you came in here for bronchitis, but let's talk about why you can't skimp on sleep or some new recommendations for colon studies," Dr. Lamm says.

Steering away from sketchy solutions

Men's health centers also aim to get men to avoid potentially harmful practices—especially websites that offer erectile-dysfunction drugs without any exam or evaluation by a doctor, and unnecessary testosterone treatments.

A major concern is "low-T" clinics that offer doses of the male hormone testosterone, marketed as a way to boost strength and sexual function. But while testosterone treatment has benefits for some men with low levels, studies show that as many as 40% of men who get therapy don't have low testosterone to start with, and a significant number don't have their levels tested before or after starting treatment.

Testosterone use tripled from 2001 to 2011, mostly in men without a clear indication that it was called for. After two studies reported an increased risk of heart attack and stroke, prescriptions dropped significantly between 2013 and 2016, according to an analysis of insurance claims data published last year. The researchers noted, however, that many men get prescriptions from clinicians not reimbursed by their insurer, so there would be no record of their use in the claims data.

Other studies have questioned the cardiovascular risks, but researchers say it remains unclear how testosterone treatment is associated with heart attack, stroke, prostate cancer and other conditions. "There are legitimate reasons for people with low testosterone to get treatment with appropriate testing and monitoring, but for men who are looking for a fountain of youth, it's not appropriate," says Ajay Nangia, vice chair of urology at the University of Kansas Health System and a spokesman on testosterone issues for the American Urological Association.

Using tech to avoid embarrassment

One of the biggest obstacles to men seeking treatment is that they're simply reluctant to talk about intimate health issues.

In surveys conducted as part of MENtion, an educational campaign launched in 2016 to urge men to discuss health issues they find hard to discuss, Cleveland Clinic found that half of men say they just don't talk about their health. When they do discuss health, they are more likely to brag about "hero" injuries like a broken arm from a bike flip gone wrong or stitches from a carpentry close call.

And there is a reluctance to seek out care even with some urgent male issues: Less than half of the men surveyed said they would see a doctor if they experienced a painful erection.

The growth in live video consult services such as Teladoc has also made it easier for men to seek help from legitimate practitioners. Now some providers are offering asynchronous consults, where patients submit questions electronically to a physician assigned to answer queries as time permits. All of which means patients never have to interact with a doctor in person.

For instance, Bright.md, of Portland, Ore., developed software called SmartExam that is being used by health-care providers and health systems to offer 24/7 access to care for more than 470 common medical conditions such as low back pain, depression, urinary-tract infections and erectile dysfunction.

Patients can use a smartphone, tablet or computer to enter symptoms and answer detailed questions; the program also accesses their electronic health records to review medical history. The software uses artificial intelligence to suggest a diagnosis and treatment plan to the reviewing clinician, including prescriptions for drugs or physical therapy, which is then reviewed, approved and finalized by the clinician.

Bright.md's vice president of marketing, Kara Kerker, says it typically takes patients 10 minutes to fill out the questions and doctors less than two minutes to review and approve the treatment plan. Doctors can also change the plan or decide the patient needs further tests or a clinic visit. Removing the need for men to have to see someone face to face, even on video, might motivate them get help sooner, Ms. Kerker says.

Meanwhile, Cleveland Clinic is piloting a program to allow men to schedule an appointment online by choosing from available time slots, "so a patient doesn't have to tell a stranger on the phone, 'I need an appointment for erectile dysfunction,' " Dr. Klein says.

Getting spouses involved

In Cleveland Clinic's 2018 MENtion It survey, 83% of women agreed with the statement "I encourage my spouse/significant other to get their health checked once a year." But 30% of men surveyed agreed with the statement, "I don't need annual health checks with a doctor, I'm healthy."

A study published last year in the Journal of Health and Social Behavior found that in heterosexual couples, women often go to great lengths to coerce men to get checkups. Sometimes the untreated problems were annoying to the point of creating a strain in the relationship.

There is some evidence that things may be improving. A survey by the American Academy of Family Physicians found that more than one in three men—up from a quarter a decade ago—say their partner has significant influence on whether they go to a doctor or not.

To overcome men's reluctance and remove the stigma of seeking care, health-care organizations have launched social-media campaigns and outreach efforts targeting both men and women.

The annual Men's Health Month in June, sponsored by the nonprofit Men's Health Network, tries to raise awareness about men's health by promoting "Wear Blue Friday" June 14 at workplaces, sports events, health fairs and other venues. Organizers also use the hashtag "ShowUsYour Blue" to encourage women and children as well as men to wear the color associated with men.

The Movember Foundation, which funds research related to prostate cancer, testicular cancer, mental health and suicide prevention, hosts an annual campaign asking men to grow mustaches and be "Mo Bros" in November while encouraging women "Mo Sisters" to participate in fundraising events, start a team and rally men in their lives to be active and have important conversations about health.

Integris Health, a large Oklahoma health-care provider, started a program dubbed Men's Health University 15 years ago to educate men and their families on the importance of men taking charge of their own health. It sponsors free wellness fairs, seminars, fitness programs and health screenings at sporting events and other venues, including programs aimed at minority groups.

Integris has sponsored car shows and cooking demonstrations, such as grilling contests emphasizing healthier cooking, that women can relate to as well. "We have to overcome the fear factor of guys not wanting to go, so we make it like more of a tailgate party," says Steve Petty, administrative director of community wellness for Integris.

The program has identified many men with serious health concerns who were guided to follow up, Mr. Petty says. For example, in a 2018 program, 67% of attendees who had blood tests were found to have abnormal blood pressure, and 40% were found to have abnormal blood-sugar levels. "By bringing men back into the health-care system, we can help them overcome one of their biggest health risks—that of just being a man," Mr. Petty says.

Ms. Landro, a former Wall Street Journal assistant managing editor, is the author of "Survivor: Taking Control of Your Fight Against Cancer." Emailreports@wsj.com .

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Credit: By Laura Landro

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