A woman attending one of my heart health presentations told me of her recent trip to the Emergency Department of our local hospital, and an overheard conversation between the (male) doctor and the (male) patient in the bed next door beyond the curtain:
“Your blood tests came back fine, your EKG tests are fine – but we’re going to keep you for observation just to rule out a heart attack”.
A male patient is thus kept in hospital for observation in spite of ‘normal’ cardiac test results. But I and countless other females in mid-heart attack are being sent home from Emergency following ‘normal’ test results like his, and with misdiagnoses ranging from indigestion to anxiety attacks to menopause. Why is this?
Women (especially younger women) with heart disease are more likely than men to be misdiagnosed. Research on cardiac misdiagnoses reported in the New England Journal of Medicine* looked at more than 10,000 patients (48% women) who went to their hospital Emergency Departments with chest pain or other heart attack symptoms. Investigators found that one in every 50 people who had suffered a heart attack was misdiagnosed and sent home from hospital. But women younger than 55 were seven times more likely to be misdiagnosed than men of the same age. The consequences of this were enormous: being sent away from the hospital doubled the chances of dying.
Dr. Jerome Groopman‘s book, How Doctors Think, helps to explain why these misdiagnoses happen in the first place:
“Specialists in particular, are known to demonstrate unwarranted clinical certainty. They have trained for so long that they begin too easily to rely on their vast knowledge and overlook the variability in human biology.”
This so-called “disregard for uncertainty” was what I faced with that Emergency Department physician in 2008 who sent me home from hospital with a misdiagnosis of GERD (gastroesophageal reflux disease), despite the fact that I’d just presented with textbook heart attack symptoms like chest pain, nausea, sweating, and pain radiating down my left arm. His emphatic but unwarranted clinical certainty:
“You’re in the right demographic to be having acid reflux!”
The medical error of misdiagnosis can include:
- a complete failure to diagnose (totally missing the disease)
- wrong diagnosis (for example, diagnosing indigestion instead of a heart attack)
- partial misdiagnosis (diagnosing the wrong subtype of heart disease or the wrong cause of the disease or its complications)
- delayed diagnosis (when a doctor does not recognize a disease until long after it should have been identified)
There is also still, amazingly, a persistent myth that heart disease is a man’s disease. Even the name of the type of heart attack I survived (the so-called “widowmaker”) tells you that semantics reflect the medical profession’s assumption that this kind of myocardial infarction hits men, not women. It’s not, after all, called the “widowermaker”, is it?
Doctors may actually be reluctant to consider heart disease when a woman has cardiac symptoms, and instead will look for other causes. A 2005 American Heart Association study showed, in fact, that only 8% of family physicians and 17% of cardiologists were aware that heart disease kills more women than men each year.
And women themselves are less likely than men to realize how vulnerable they are to heart disease. A number of studies report that women are more likely to delay seeking treatment even when they experience serious cardiac symptoms. A 2009 survey, for example, suggests that only half of women indicated they would call 911 if they thought they were having a heart attack (and that’s down from 80% just five years ago!) and few were even aware of women’s most common heart attack symptoms. And those symptoms can be more vague and atypical compared to men’s ‘Hollywood Heart Attack‘ symptoms. See also: What Does a Girl Have To Do To Get Her Heart Attack Noticed?
Even first-responders like ambulance paramedics are less likely to provide standard levels of care to women who call 911 with cardiac symptoms compared to their male counterparts, according to a study at the University of Pennsylvania.
Researchers found significant differences in both aspirin and nitroglycerin therapy offered to women vs. men. In fact, this study showed that of the women transported to hospital by ambulance who were suffering from heart attacks, not one was given aspirin by paramedics en route. See also: How Can We Get Heart Patients Past the E.R. Gatekeepers?
Once women do arrive at hospital, both nurses and physicians working in Emergency Departments report a bias towardslooking for heart attack pain symptoms, even though a majority acknowledge that women often present with vague, non-pain symptoms during a cardiac event. About 40%, for example, do not have any chest symptoms at all.
Why don’t diagnostic tests pick these up? Women are less likely than men to receive some cardiac diagnostic tests in the first place, and some tests don’t work as well in women. Most tests for diagnosing heart disease have been fine-tuned in studies focused on men. The treadmill stress test, for example, has been found to be far less accurate in women than in men, and particularly for identifying single vessel or non-obstructive heart disease – which are both more common in women.
The ‘gold standard’ test for diagnosing coronary artery disease in both men and women is the angiogram, but studies also show that women are less likely than men to be referred for angiography. And some types of non-obstructive heart disease like Prinzmetal’s Angina do not show up during angiography unless the coronary artery spasm happens to actually occur during the procedure.
How to help yourself get an accurate diagnosis:
What to do if you think you’ve been misdiagnosed:
- Do not feel embarrassed to speak up
- Get more tests/ask for repeat tests
- Get a second opinion
- Keep going back until you are diagnosed accurately!
Dr. Jerome Groopman further recommends that you ask these questions of your doctor:
- “What else could it be?” The cognitive mistakes that account for most misdiagnoses are not recognized by physicians; they largely reside below the level of conscious thinking. When you ask simply: “What else could it be?”, you help bring closer to the surface the reality of uncertainty in medicine.
- “Is there anything that doesn’t fit?” This follow-up should further prompt the physician to pause and let his/her mind roam more broadly.
- “Is it possible I have more than one problem?” Posing this question is another safeguard against one of the most common cognitive traps that all physicians fall into: search satisfaction. It should trigger the doctor to cast a wider net, to begin asking questions that have not yet been posed, to order more tests that might not have seemed necessary based on initial impressions.
© 2009 Carolyn Thomas www.myheartsisters.org
* Pope JH, Aufderheide TP, Ruthazer R, et al. Missed diagnoses of acute cardiac ischemia in the emergency department. N Engl J Med. 2000;342:1163-1170.
Please note: information on this site is not meant as a substitute for medical advice
- Cardiac Gender Bias: We Need Less TALK and More WALK
- The Sad Reality of Women’s Heart Disease Hits Home
- Misdiagnosis: the Perils of “Unwarranted Certainty”
- Seven Ways To Misdiagnose a Heart Attack
- The ’18 Second Rule': Why Your Doctor Missed Your Heart Attack Diagnosis
- Things Your Doctor May Not Know
- Experts: Why So Wrong So Often?
- How to Be a Good Patient
- Seven Ways to Misdiagnose a Heart Attack
- It Wasn’t Heart Disease – But What Was It?
- What Doctors Really Think About Women Who Are ‘Medical Googlers’
- Women’s Cardiac Care: is it Gender Difference – or Gender Bias?