Take it from me: the only thing worse than a heart attack is being misdiagnosed and sent home from hospital while you’re having it. And for women in particular, this is a tragically all-too-common reality. Research on cardiac misdiagnoses reported in The New England Journal of Medicine(1), for example, looked at more than 10,000 heart patients (48% of them women) who had gone to their hospital Emergency Departments with chest pain or other significant heart attack symptoms. Women younger than 55 were SEVEN TIMES more likely to be misdiagnosed and turned away from the E.R. than their male counterparts.
The consequences of this reality for women were enormous: being sent home from the hospital in mid-heart attack doubled their chances of dying.
Some of the most popular cardiac misdiagnoses that heart attack survivors have told me about include physician guesses like indigestion, menopause, stress, gall bladder issues, exhaustion, pulled muscles, dehydration and more. But perhaps the most distressing misdiagnosis to trip from the lips of an Emergency Department physician is “anxiety”. This one single word is instantly both dismissive and embarrassing. And worse, to have the diagnosis of “anxious female” recorded permanently on a woman’s chart virtually guarantees a definitive psychiatric stereotype for all future medical visits.
Kathleen is one woman who knows what it’s like to be saddled with that “anxious female” tag. After surgery to remove a brain tumour, she wrote me in April from Oakland, California to share her own experience of being so labelled:
“I discovered that my original primary doc had added ‘anxiety’ to my official list of conditions back in 2005. I was severely hypothyroid, it turned out, with a TSH of 11.2, but he never reconsidered his ‘anxiety’ diagnosis, which, from that day forward, was at the top of my medical record.
“And that diagnosis isn’t just a comment: in my medical record, The Problem List is the very first thing every single doctor sees, after my name and file number, and (being an alphabetical list) ‘anxiety’ is at the very top.
“When I began to search for another doctor, I was unaware that this diagnosis would follow me. I have no doubt that it set the stage for the references to ‘anxious female’ that then appeared throughout my HMO files.
“My medical history is long and complex, including an ominous family cardiac history on both sides as well – certainly not suitable for docs who like easy cookie cutter diagnoses.
“I am convinced that ‘anxiety’ has been an obstacle to my appropriate diagnosis and treatment.”
In 2008, the disturbing results of a Cornell University study(2) called Gender Bias in the Diagnosis, Treatment, and Interpretation of Coronary Heart Disease Symptoms were presented at a scientific meeting hosted by the Cardiovascular Research Foundation. The study examined whether physicians tend to evaluate heart patients differently despite comparable symptoms and risk factors – based only on their gender.
The study’s results might seem distressingly familiar to any woman who has ever been (mistakenly) told, as I was: “It is NOT your heart!” by those with the letters M.D. after their names.
Half of the patient charts used in this study indicated that a patient had recently experienced a significant life stressor and that they appeared anxious. Each physician read one version of the record and was then asked to specify a diagnosis, make treatment recommendations, and indicate the probable cause of the described symptoms.
Results showed a significant gender bias when heart disease symptoms were presented in the context of stress, with fewer women receiving coronary heart disease diagnoses (15% vs 56%), cardiologist referrals (30% vs 62%), and prescriptions of cardiac medication (13% vs 47%) compared to the men.
Researchers also found that the presence of stress shifted the interpretation of women’s chest pain, shortness of breath and irregular heart rate so that these were thought to have a psychological origin.
By contrast, men’s identical symptoms were perceived as cardiac whether or not emotional stressors were present.
As Dr. Alexandra J. Lansky, director of the Women’s Health Initiative at the Cardiovascular Research Foundation said at the time:
“We know that there is a delay in diagnosing coronary heart disease in women, and this study is an important step forward in understanding why.”
The trouble is, dear readers, there are very few experiences in life more anxiety-producing than fearing you might actually be experiencing a heart attack.
Unless you present to Emergency in a coma, in fact, my guess is that most of you would certainly be displaying clear signs of extreme anxiety while in the throes of a cardiac event.
So if you’re a woman, you might be alarmed to learn that this study’s results predict that your heart attack symptoms are significantly more likely to be misinterpreted as merely stress-related compared to men with the same symptoms. And then, on top of physically distressing cardiac symptoms, you’ll also be suffering profound embarrassment and shame over “making a fuss about nothing”.
As another of my readers explained:
“For 10 years before finally being correctly diagnosed with atrial fibrillation, I experienced: palpitations, pounding heart and accelerated heart rate, sweating, trembling/shaking, shortness of breath, chest pain/discomfort, feeling dizzy and lightheaded, and fatigue. My inexperienced (and former) PCP was convinced the symptoms were due to anxiety, and a young cardiologist was quite dismissive (those pesky “women of a certain age”).
“Eventually my episodes were so frequent that A-Fib was captured on an ECG. Years later, I pulled my medical records and read that the 28 year old PCP had written I had ‘magical, mythical thinking’ about my health.”
What can women do about this systemic gender bias? Here’s what our patient Kathleen reported that she has done since discovering that “anxious female” descriptor in her own medical records:
“I have called those docs on their use of that ‘anxious female’ label and will NOT accept explanations like: ‘It’s really not what you think. Anxiety is normal in a setting like this’ or ‘That’s my way of saying that a patient needs a little extra time…’
“I sent several relevant links to one of those ‘anxious female’ docs who was humoring me. When I told him that a growing body of research shows that these biases and labels are detrimental and dangerous, he said he would be interested in references. Perhaps he is humoring me this time too, but I gave him a bunch – including a link to that New England Journal of Medicine study reported here on Heart Sisters.(1)
“A false ‘anxiety’ flag on my chart does not help me.“
UPDATE: See Kathleen’s comment (below) in which she tells us: “I would like to report that ‘Anxiety’ has been removed from my official Problem List, finally. Past records will not be changed, but it no longer tops my records. I’m still working for educational discussion of this experience, to reduce likelihood of others suffering from the same error and dismissal.”
© Carolyn Thomas ♥ Heart Sisterswww.myheartsisters.org
Q: Have you been mistakenly labelled an “anxious female” during a serious health crisis?
NOTE FROM CAROLYN: I wrote much more about both misdiagnosis and anxiety in my book, A Woman’s Guide to Living with Heart Disease . You can ask for it at your local library or favourite bookshop, or order it online (paperback, hardcover or e-book) at Amazon, or order it directly from my publisher, Johns Hopkins University Press (use the code HTWN to save 20% off the list price).
(1) Pope JH et al. “Missed diagnoses of acute cardiac ischemia in the emergency department”. N Engl J Med. 2000;342:1163-1170.
(2) Chiaramonte G et al. “Gender Bias in the Diagnosis, Treatment, and Interpretation of CHD Symptoms”. Cardiovascular Research Foundation. 2008, October 12. ScienceDaily. 2008/10/081012121314