Unconscious bias: why women don’t get the same care men do

~ Carolyn Thomas

by Carolyn Thomas   ♥  @HeartSisters

To the surprise of absolutely no women who have ever been misdiagnosed in mid-heart attack as I was, Dr. Mary O’Connor, claims:

“Women do not always receive the same medical care as men.”

OConnor-781x1024In her article called The Woman Patient: Is Her Voice Heard?, Dr. O’Connor, a Professor Emerita of orthopedics at Mayo Clinic, shares her perspective on how gender affects the medical care of women today.

How can this possibly still 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 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, for example, are based on cardiac research done primarily on (white middle-aged) 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. 

“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 from Canada, where access to physicians is not a financial 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 in their 50s or younger who are experiencing a heart attack are seven times more likely to be misdiagnosed and sent home from the Emergency Department 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.  See also: Women’s Heart Disease: Wrong Symptoms, Wrong Words or Wrong Diagnostic Tools?

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?

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.

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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 30% off the list price when you order).

See also:

Fewer lights/sirens when a woman heart patient is in the ambulance

Yentl Syndrome: Cardiology’s Gender Gap is Alive and Well

Cardiac Gender Bias: We Need Less TALK and More WALK

The ‘Bikini Approach’ to Women’s Health Research

How Can We Get Heart Patients Past the E.R. Gatekeepers?

Women and Heart Disease: Gender Differences

How to Be a Good Patient

Seven Ways to Misdiagnose a Heart Attack

Women’s Cardiac Care: is it Gender Difference – or Gender Bias?

Heart Attack Misdiagnosis in Women

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Published by Carolyn Thomas

34 thoughts on “Unconscious bias: why women don’t get the same care men do”

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  9. I am a 23yr old Female. I got diagnosed with Takayasu’s Arteritis October 2012. I have 100% blockage in my left carotid artery and now 69% blockage in my right carotid artery. My right carotid artery has gone up 19% since a few months ago. Yet, my Male Doctor is telling me it’s stable. I have had numbness in my left arm, seen black spots out of my left eye. I know there is something wrong. But he has even told me I am too young for anything to happpen and doesn’t want to have to do surgery. I wish I could afford to go to Mayo Clinic. I want to be treated like everyone else regardless of my age and gender. I have also been to the ER several times and just sent home.

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    1. Hello Jamie – this tough diagnosis often strikes young women. Medications are usually the first line of treatment (surgery if meds like prednisone aren’t effective). Consider asking for a second opinion. Hang in there . . .

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      1. Thank you for replying back. I was on prednisone from October 2012 to March 2013 and methotrexate from December 2012 till October 2013. I will definitely be looking into getting a second opinion. Thank you for your time.

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  10. Far too many doctors – the majority, I believe – tend to stereotype women patients as people who exaggerate their pain, and when a woman reports physical symptoms, these doctors (and dentists too, in my own case!) look for a psychogenic explanation rather than rigorously examining for physical causes of the symptoms.

    There is an excellent article about this (Lennane and Lennane, “Alleged Psychogenic Disorders in Women“) which, although written in 1973, is still largely true today.

    The article is included in various books, including “The Changing Experience of Women”, Open University Press. It is largely the Social Sciences that have explored these damaging medical attitudes toward women patients, the attitudes being those of the medical profession, rather than those of male doctors in particular.

    And here are some rather strange research findings from Sweden.

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    1. Hello Margaret and thanks for your comments here. Your dental abscess nightmare is an amazing and tragic story. And that article on the Swedish study was definitely “strange” (not the research findings, but the author’s interpretation!)

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  11. Carolyn,

    Great article!

    I agree that some of it is unconscious bias; I also think that some of it is communication differences. I talk about that in both articles listed below, which may be of interest. They are based on atrial fibrillation patients, but apply to heart patients, and really, to all patients.

    I hear far more complaints from women than from men about how their doctors treat them. Communication and Respect are two HUGE issues women have with their doctors.

    1) Gender Matters: Why Afib is More Fatal for Women:

    2) A Matter of Trust: How to Build Adherence with Afib Patients:

    Here is one suggestion for healthcare providers from the articles above:

    “Listen for what is said, and what is not said, and ask clarifying questions. Some women communicate with emotion rather than facts, so you may have to listen closely to distill symptoms and side effects from what is said.”

    We have to do a better job of helping our doctors learn how to listen to us as well as how to communicate so that they will listen. It shouldn’t be our job, but it will take years and decades to change how doctors communicate with us, and in the meantime, we have to protect ourselves. It is not optimal, but it is reality!

    Mellanie True Hills, atrial fibrillation survivor

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      1. Carolyn,

        Thanks. Regarding your link above, you may find the video interview I did with Dr. Mandrola, when he first presented his findings at AHA, to be of interest.

        Also, as an atrial fibrillation survivor, my site is considered one of the top afib sites on the web.

        Keep up the great work.

        Mellanie

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  12. Hi Carolyn. Thank you for this most important topic!

    I had a widowmaker heart attack 11 years ago at age 48. I had pain in my jaw and neck, tunnel vision, sparkles in my peripheral vision, sweat through my clothes, had difficulty breathing, etc. – and the ER sent me to a dentist.

    I told them I’d never had a toothache like that in my life and they blamed my age. I guess they believe that menopause brings extra pain sensitivity (sarcasm over). The dentist immediately called an ambulance, stuck an aspirin in my mouth, and went with me to a university medical center. He may have saved my life. It was the widowmaker.

    I found most cardiologists jump right to the A word – anxiety – even though I brought all my records from my heart attack, about my hypertension and treatment, pre-eclampsia, my father’s cardiology records (he had his first heart attack at age 46), etc.

    GERD also comes up too frequently. Every doctor I go to, I bring articles relating to women and heart disease. Those statistics you mention about the death rate from heart disease – are they on the Heart Association web page? I’d like to bring those to my next appointment.

    Finally, I found a wonderful cardiologist. I actually was afraid of him sight unseen because he is a 70 year old man, but I went to the appointment anyway. My pre-conceived notion was that he trained in the old days, and would be biased. I was totally, completely, 100% wrong. I suspect one of these days he will turn into Dr. Lown.

    Again, Carolyn, thank you for this.

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  13. “Or must we mistrust every medical opinion?”

    I’ve learned (the hard way) to not exactly ‘mistrust’ every medical opinion but to examine it thoroughly with a skeptical eye abetted by the Internet and a critical, thinking mind.

    On the topic of gender bias—-When I first became ill (a disease, not heart problems) I naively asked my doctor to do an EKG because of heart palpitations (later found to be associated with my disease). He refused. Two times.

    I then asked my husband to come in with me and request an EKG. Done! Not a whimper from the doc!

    But I also had a viper of a woman doctor be as nasty a one as can be encountered. 🙂

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    1. OMG. That story of your husband’s presence finally affecting the doc’s approval of your diagnostics is UNBELIEVABLE. It’s like you were the helpless child and your hubby was the powerful parent. Arrrggghh….

      And personally, although I do prefer a woman GP, I’ve had too many experiences of wonderful care from male docs and unacceptable care from female docs to make any judgements about which are “better”!

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      1. I did forget to mention that I, too, have had some wonderful male doctors. Had to kiss a lot of frogs though. 😦
        Here is something else related to gender:

        Huffington Post posted a list of things that women couldn’t do in 1913 but can now.

        Then a much shorter list posted the things they still can’t do.

        In 2013, women still can’t

        1. Necessarily access legal abortion.
        2. Purchase emergency contraception at a pharmacy without a prescription.
        3. Have paid maternity leave.
        4. See people of their gender equally represented in politics or at the top of U.S. companies.

        Read more on this here.

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    2. I have experienced just too many confident misdiagnoses, and serious ones, to consider “trust” more than a relative concept, and we are always fighting uphill against the accretion of social baggage in regard to women.

      Any doc who does not explain in depth and engage in discussion, even debate, does not merit my confidence, and even some of those really good ones – male or female – are still sometimes wrong.

      The story of your husband, on the first try, getting you the EKG you had been twice denied reminds me of the documentary film: The Tillman Story. About football player Pat Tillman, who enlisted in the army after 9-11 and was killed by U.S. fire in Afghanistan, then covered-up, and his family had to fight for the truth.
      In any case, his mother had doggedly met with officials, civil and military, had petitioned for documents, had done long, hard, persistent work to meet nothing but roadblocks. And when his father came with her to a meeting with (I think) Army brass, he blows up and hurls epithets that are probably beneath the tone of this blog. And what happens? The documents Mary Tillman had been trying to get arrives. Soon. And one of their sons remarks on exactly that on camera. They ignored exemplary work but responded to epithets.

      Worth watching for many reasons, but it was recommended to me by yet another medically ignored woman.

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        1. Exactly. So what do we need to do to get attention?
          My (former) PCP considered the very fact that I was meticulously recording data (on something that he insisted was benign, but had a serious impact on my life, as anyone who looks at the data can see) as yet further evidence that I am unbalanced. You know: Anxious Female.

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  15. Hi Carolyn,

    I look forward to the day you no longer have to write such an essay. That day cannot come soon enough!

    JG

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      1. Oh, don’t we live this every time we see a new doc!! I see signs of improvement in my 4 1/2 yrs of this journey – or maybe I’ve just become better at identifying the patronizing ones.

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        1. But how do we know? If I become one of that huge group of women Dr. O’C mentions whose doctor tells me I don’t need knee-replacement surgery, for example – I’d most likely believe it, right? Or must we mistrust every medical opinion?

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          1. This liberation from old attitudes and stereotypes is a long slow journey. I think we just have to continue to keep informed and be ongoingly assertive in order to be taken seriously.

            Your blog is a good example of this Carolyn. Keep up the good work!

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