The Default Patient

How Medicine Learned the Male Body First

A middle-aged man develops crushing substernal chest pain radiating down his left arm. He becomes diaphoretic, nauseated, and short of breath. Medical students recognize the diagnosis almost immediately because this presentation has become one of the most recognizable clinical vignettes in medicine. Even without a medical degree, most people can recognize the symptoms of a myocardial infarction (heart attack).

A middle-aged woman presents with fatigue, dyspnea, nausea, epigastric discomfort, and a vague sense that something is wrong. She, too, is presenting with symptoms that point towards a myocardial infarction. For decades, these symptoms were often described as “atypical.”

The language itself is interesting. If nearly half the population experiences disease differently, at what point does atypical simply mean different from the original reference group?

Medicine, like all sciences, requires a starting point. Historically, the male body often became that starting point: the reference body through which physiology was learned, disease was characterized, and therapies were developed. The consequences of that decision continue to shape healthcare today.

Difference Was Never the Problem

The history of medicine is not a story of physicians failing to recognize that men and women were biologically different. Quite the opposite. Ancient physicians devoted enormous attention to menstruation, fertility, pregnancy, childbirth, and menopause. The existence of reproductive physiology made sexual dimorphism impossible to ignore.

This is an important fact: women’s health was never absent from medicine. Instead, it often occupied a distinct intellectual space centered primarily around reproduction and reproductive physiology. The uterus was studied extensively. Pregnancy was studied extensively. Childbirth was studied extensively. Outside of those domains, however, many principles of physiology, pharmacology, and disease increasingly developed from populations that were disproportionately male.

As modern biomedical research evolved, this approach became increasingly understandable from a methodological standpoint. Researchers sought homogenous populations, fewer confounding variables, and simpler study designs. Hormonal cycling introduced variability. Pregnancy introduced ethical concerns. The thalidomide tragedy of the mid-20th century further amplified concerns regarding fetal exposure during clinical trials.

None of these decisions were irrational. Researchers were attempting to improve safety, reduce complexity, and generate cleaner datasets. Yet understandable decisions can still produce unintended consequences.

As medicine increasingly learned its principles of disease and therapeutics through male populations, the male body gradually became the reference point from which differences were measured.

The Consequences of a Default

Defaults are powerful because they become invisible.

Once a reference point becomes established, deviations from that reference begin to appear unusual, even when they are common. This may explain why women have historically been described as having “atypical” presentations of cardiovascular disease despite representing half of all patients with cardiovascular disease, not to mention contributing to more than 20% of all female deaths in the US.

Pharmacology offers similar examples. In 2013, the recommended dose of zolpidem (Ambien) for women was reduced after evidence demonstrated slower clearance and higher morning blood levels compared to men, increasing the risk of next-day impairment. The medication had not changed. Women’s metabolism had not changed. What changed was the recognition that the original assumptions did not apply equally to everyone.

Pain may represent an even more complicated example. Women report higher rates of chronic pain conditions, autoimmune diseases disproportionately affect women, and emerging evidence suggests important sex-based differences in immune signaling and pain processing. Yet many of these differences only began receiving significant scientific attention relatively recently.

Some readers may recognize a familiar pattern emerging here. In Functional Enough, I explored how women’s pain is often normalized rather than investigated. In How Medicine Lost the Clitoris, I examined how anatomy can become functionally invisible when institutions direct their attention elsewhere. The issue is rarely malice. More often, it is attention.

What receives attention tends to receive resources - the squeaky wheel gets the grease. What receives resources tends to generate knowledge.

The Correction

Medicine has not ignored these problems.

In many ways, the past three decades have represented one of the most significant shifts in biomedical research since the rise of the randomized controlled trial itself. Recognition that the evidence guiding medical care may not always apply equally to men and women prompted both regulatory and scientific changes intended to broaden participation in clinical research.

The NIH Revitalization Act of 1993 represented one of the most important milestones in this process, mandating the inclusion of women in federally funded clinical trials and encouraging investigators to consider sex as an important biologic variable rather than a confounding one. The implications of that change continue to unfold today.

Increasingly, researchers ask questions that would have seemed unusual only a generation ago. Does this medication work differently in women? Does this disease present differently? Are adverse effects distributed equally across populations? Are treatment outcomes influenced by hormonal state, reproductive status, or menopausal transition? Questions once considered niche have become central to modern clinical investigation.

The result has been a gradual shift away from the idea of a single reference patient and toward a more nuanced understanding of human physiology. Pharmacokinetics, cardiovascular disease, autoimmune disorders, pain science, and sleep medicine have all benefited from this approach. In many respects, medicine has become more accurate precisely because it has become less universal.

Importantly, this movement is not about replacing one default with another - the goal is not a male version of medicine and a female version of medicine - but rather a medicine sophisticated enough to recognize meaningful biologic differences when they exist and equally sophisticated enough to recognize when they do not.

Variability Is Biology

Historically, medical research often sought simplicity through standardization. Variability complicated analysis, increased costs, and reduced statistical power. The cleaner the dataset, the easier the conclusions became.

The unintended consequence was that some of the very experiences defining women’s physiology became underrepresented in the evidence intended to guide their care. Menstruation is not noise in the data. Pregnancy is not noise in the data. Menopause is not noise in the data. These are normal physiologic states experienced by half the population.

The challenge facing modern medicine is therefore not correcting bias so much as expanding perspective. Medicine began with the bodies that were easiest to study, easiest to standardize, and easiest to compare. Over time, those bodies became the reference point against which others were measured.

Defaults are powerful because they eventually become invisible.

Perhaps the goal of modern medicine is not to eliminate the default patient, but to recognize that no single patient was ever truly default to begin with.

Half the population was never atypical.

© 2026 Corey R. Babb, DO, FACOOG, IF, MSCP