To the surprise of absolutely no women who have ever been misdiagnosed in mid-heart attack as I was, Dr. Mary O’Connor of Mayo Clinic claims:
“Women do not always receive the same medical care as men.”
Trouble is, Dr. O’Connor didn’t make this disturbing statement five years ago.
That’s when I was sent home from the E.R. by a physician who took one look at me and – despite my textbook heart attack symptoms of chest pain, nausea, sweating and pain radiating down my left arm – pronounced confidently:
“You are in the right demographic for acid reflux!”
No, Dr. O’Connor wrote this just a few weeks ago for the Sharing Mayo Clinic website.
In her article called The Woman Patient: Is Her Voice Heard?, Dr. O’Connor – who chairs the Department of Orthopedics at Mayo Clinic’s Florida venue – shares her perspective on how gender still affects the medical care of women today.
How can this possibly be happening, given all that’s been studied and written about gender imbalance in medical care? Dr. O’Connor explains:
“This is not a simple issue. There are many factors that influence the patient-physician interaction and relationship. But the factor that may be the most powerful may be one we know surprisingly little about in the health care setting: unconscious bias.
“Unconscious bias may be the reason women receive fewer kidney transplants and heart surgeries.
“It may be so powerful that it even influences the care provided to children. A 2011 study by Butani and Perez showed girls are 22 percent less likely to be placed on a kidney transplant list than boys. Because an earlier transplant equates to better health, this gender disparity likely impacts the long-term outcome of these young women.”(1)
In the wonderful world of women and heart disease, many of us are all too aware of how this unconscious bias may be playing out every day. Most of our current diagnostic tests and subsequent treatment decisions are based on cardiac research done on white male subjects, or with females represented in statistically insignificant numbers. Cardiologist Dr. Sharonne Hayes (founder of the Mayo Women’s Heart Clinic) adds:
“Misconceptions about women’s heart disease grew roots decades ago. In the 1960s, erroneous assertions that heart disease was a man’s disease were widely spread to the medical community and to the public.
“This led to research almost exclusively focused on cardiovascular disease in men.
“There is no good study out there that tells us how similar or different women are from men when it comes to heart attacks. Part of the problem now is also that clinical practice guidelines are less likely to be applied to women compared to men.”
As in many other fields of medicine, scientific research has historically focused on men, with two-thirds of all diseases that affect both men and women studied exclusively in men.
Dr. O’Connor points to her own field – orthopedic surgery – as one that’s not immune to unconscious bias.
“While there are always outliers, my professional colleagues are wonderful people truly dedicated to providing outstanding care to all their patients. My male colleagues have operated on my family and me with my complete trust.
“Yet research show that unconscious gender bias exists, and that it impacts patient care.”
She cites, for example, a study performed in Canada, where access to physicians is no barrier, that looked at the effect of gender on physician recommendations for knee-replacement surgery. The study found that orthopedic surgeons were 22 times more likely to recommend knee-replacement to men than to women with the same diagnosis, symptoms and clinical presentation.(2)
But here’s where Dr. O’Connor widens her belief in what causes these types of blatant gender differences:
“I believe that the source of this unconscious bias seen in medicine is a bias against women deeply rooted in our society.
“Of course we want to believe that we see everyone as equal. But in reality we do not.
“We are socialized to believe that women are more likely to have pain than men, or at least are more willing to complain of pain than men. Furthermore, women are seen as the “weaker sex” and our decisions may be negatively influence by the “time of the month” or hormonal status. While we know that there are true biological difference in pain pathways, physical strength and hormonal levels, these differences are framed in a negative light for women.
“Doctors see female patients through this spectrum. The unconscious thought is that women:
- will be more difficult to manage from a pain standpoint after surgery
- will take longer to recover
- will require a longer hospital stay, more visits to the office, and more phone calls
- are more likely to be obese (another important bias topic!) making the surgery more physically demanding for the surgeon and increasing the risk of postoperative complications”
In a landmark study reported in the New England Journal of Medicine researchers found that women under the age of 55 who are experiencing a heart attack are seven times more likely to be misdiagnosed and sent home from the E.R. compared to their male counterparts presenting with identical symptoms. The consequences of this are enormous: being sent away from the hospital doubles the chances of dying.(3)
We know that Emergency personnel are still sending home women suffering cardiac events, misdiagnosed with indigestion, anxiety or menopause (a great all-purpose misdiagnosis). And we’re not only under-diagnosed, we are under-treated even when appropriately diagnosed.
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, so instead will look for other causes. A 2005 American Heart Association study showed, in fact, that only 8% of family physicians and – even worse! – just 17% of cardiologists were aware that heart disease kills more women than men each year (a statistic that’s been true since 1984). Read that last line again. Cardiologists! This is their business. This is all they do.
Are there any solutions to the alarming problem of unconscious bias in our health care professionals? Dr. Mary O’Connor answers:
“How do we combat unconscious bias in medicine? We work on increasing awareness of biases by both physicians and patients. In addition to gender, race and ethnic bias can be present.
“After awareness comes education, with a focus on how physicians can limit the impact of bias in decision-making.
“We work on improving the diversity of the medical workforce. I do believe that if we had more women and minority orthopedic surgeons, for example, we would change the culture of the profession. I am embarrassed to write that orthopedic surgery has the lowest percentage of women in residency training programs of any surgical specialty.”
(1) Effect of pretransplant dialysis modality and duration on long-term outcomes of children receiving renal transplants. Butani L, Perez RV. Transplantation. 2011 Feb 27;91(4):447-51.
(2) The effect of patients’ sex on physicians’ recommendations for total knee arthroplasty.
Borkhoff CM, Hawker GA, Kreder HJ, Glazier RH, Mahomed NN, Wright JG. CMAJ. 2008 Mar 11;178(6):681-7.
(3) 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.
Q: How can we help make sure women’s voices are indeed heard?
NOTE FROM CAROLYN: I wrote much more about the gender gap in cardiology in my book A Woman’s Guide to Living with Heart Disease (Johns Hopkins University Press, 2017). You can ask for this book at your local bookshop, or order it online (paperback, hardcover or e-book) at Amazon, or order it directly from Johns Hopkins University Press (use their code HTWN to save 20% off the list price when you order).