Imagine the reaction from Emergency Department staff to the woman I met at my Mayo Clinic training, the one who had been sent home from Emergency three days in a row despite her complaints of increasingly distressing cardiac symptoms. Each time she arrived there, she clearly declared the following to the Emergency physician, who continued to repeatedly dismiss her concerns:
“I don’t care what you say. SOMETHING is wrong with me!”
What a royal pain in the ass, staff may have muttered about her, sotto voce.
On her third visit, the physician recommended anti-anxiety medications. But on the fourth visit, on that fourth day, she was taken directly from the E.R. to the O.R. to undergo emergency coronary bypass surgery.
How we communicate to physicians is a profoundly important issue for women with heart disease, because, like my Mayo friend and me, women are far more likely to be misdiagnosed compared to our male counterparts. See, among many other reports (here, here, and here, for example) the 2018 Heart and Stroke Foundation report, Ms. Understood.
In my response to that document, I quoted Mayo Clinic cardiologist Dr. Sharonne Hayes, founder of the Mayo Women’s Heart Clinic, on the very real difference in how male and female heart attack patients are still being treated by Emergency Department gatekeepers (even when women’s cardiac enzyme blood tests for troponins – an accepted marker for heart attack – are elevated):
Researchers continue to describe this reality as the cardiology gender gap, blamed in part on the implicit bias against women among many medical professionals, and in part on women themselves, mostly because of how we communicate our symptoms to physicians.
Many women, for example, do not use the word “pain” at all to describe chest symptoms during a heart attack. We may instead minimize chest symptoms by describing them as fullness, heaviness, pressure, burning, tightness, aching – but not necessarily “pain”. And some women experience no chest symptoms at all.(1)
Yet almost all cardiac diagnostic/treatment guidelines worldwide clearly mention “chest pain” as a required tick box on a symptom checklist if women want to be believed in mid-heart attack. For some paramedics and Emergency staff, “no chest pain” = no heart disease.
Women also tend to worry about being perceived as a “difficult patient”. We are far more likely to apologize for wasting doctors’ time compared to our male counterparts, for example. We try to be “nice”. We are reluctant to “make a fuss”. We will remain quiet and respectful while we’re being treated dismissively or disrespectfully. This is so common, in fact, that there’s an entire field of research focused on women’s treatment-seeking delay behaviours during a cardiac event.
And we are correct to worry about this “difficult patient” perception, because researchers tell us that the quality of care we receive (or not!) can be affected by how physicians perceive us. How we speak, the words/tone/volume when we do speak – even our age or ethnicity – are all rapidly assessed, sometimes even contributing to women’s higher cardiac misdiagnosis rates.
Back in 2008, while experiencing terrifying heart attack symptoms (central chest pain, nausea, sweating and pain radiating down my left arm), I asked the Emergency doctor (who had just misdiagnosed me with acid reflux) about this alarming pain in my arm. And a few minutes later, I was scolded by his nurse in no uncertain terms:
“You’ll have to stop asking questions of the doctor. He’s a very good doctor, and he does NOT like to be questioned.”
Her stern warning to me left no doubt in my mind that I was, in fact, a “difficult” patient because I’d had the temerity to ask a question. I felt so humiliated and embarrassed, I couldn’t get out of there fast enough, and although symptoms returned and worsened every day, it would take me two weeks before I finally forced myself to return to that Emergency department because this “acid reflux” pain by then was unbearable.
By the way, the question I’d had the temerity to ask was: “But Doctor, what about this pain down my left arm?”
Speaking of women being “nice”: whatever your opinion of the Supreme Court judiciary committee hearings in the U.S. (and that’s most likely precisely the same opinion you held before watching that highly politicized event), the televised interrogation of Dr. Christine Blasey Ford and Judge Brett Kavanaugh was a remarkably clear example of the differences in male and female communication styles that persist, no matter how high the stakes.
As Maggie Haberman, White House correspondent for the New York Times, observed:
“Regardless of whether Ford is right about what took place or Kavanaugh is, if any woman who felt wrongly accused fought for her life by crying, yelling and being obstinate with senators, she would be eviscerated as crazy, hysterical, and weak.”
Dr. Deborah Tannen agrees with Maggie. The longtime professor of linguistics at Georgetown University and author of many books (including my personal favourite, “You Just Don’t Understand: Men and Women in Conversation”) analyzed the linguistic gender dynamic for PBS News Hour’s Amna Nawaz at the time:
“The contrast between the two was striking. It was a stereotypical representation of how women and men would be expected to present themselves and behave. He was blustery, he was taking up as much talk space as possible. His anger was an emotion that is approved of and often seen as positive in men.
“But (Dr. Ford) could NOT be angry, although she had much reason to be, but it would be very unacceptable for her to have shown anger. Everything about her communication was deferential.
“Meanwhile, he was interrupting the senators. He was disrespectful to the senators. He turned the questions back upon the senators.”
That woman I met at Mayo? She was taking a big risk when she abandoned being nice in favour of being persistent and assertive, yet it turns out that she was also much smarter than I was.
Unlike me, she pushed through her reluctance to be seen as “difficult”, ignoring whatever embarrassment she felt about “making a fuss” time after time despite the dismissive reactions of Emergency Department staff – until she was finally correctly diagnosed and appropriately treated.
Yet patients like me and my Mayo friend walk a razor-sharp tightrope. We risk being labelled as “difficult” if we persist, yet we risk being dead if we don’t.
The reality is that most men do not have to fight to be believed, either when reporting cardiac symptoms in an Emergency department, or when reporting criminal assault.
Women shouldn’t have to, either.
You know your body. You know when something is just not right. Speak up. Stand up. Show up.
Because just being “nice” is not working for us anymore.
*PS: In my book, “A Woman’s Guide to Living with Heart Disease“ (Johns Hopkins University Press, 2017), I wrote much more about doctor-patient communication, and offered these tips for appropriately and assertively communicating your cardiac symptoms to physicians:
- Adjectives are important. Use descriptive words like dull, throbbing, intense, burning, tingling, heavy or piercing.
- Describe how symptoms change your daily life and ability to function. Instead of just saying you feel “tired”, talk about specific changes in your day-to-day life (“Can no longer carry laundry basket up the stairs.”)
- Describe a location for your symptoms. Point to specific body parts if necessary.
- Start a Symptom Journal to help you track what you’re experiencing. Date/time of day/ what you were doing/eating/feeling in the hours leading up to symptoms, e.g. ‘I feel worse at night or whenever I walk up our steep driveway.”
- Be insistent about your symptoms if it feels like your physician isn’t getting it. Do not minimize or self-diagnose (e.g. “This is probably just a pulled muscle…”)
- If you feel embarrassed (for example, if you fear you may be judged or criticized for smoking), try saying, “This is hard to talk about, but I need your help.”
- IF SYMPTOMS PERSIST/WORSEN AFTER YOU ARE SENT HOME FROM EMERGENCY, do not be like me! Be like my Mayo Clinic friend who kept going back. Do not be embarrassed to death.
(1) J. Canto et al, “Association of age and sex with myocardial infarction symptom presentation and in-hospital mortality,” JAMA. 2012 Feb 22;307(8):813-22.
NOTE FROM CAROLYN: Please do NOT leave a comment here listing your current symptoms. I am not a physician and cannot advise you what to do. If you are concerned that you might be experiencing a cardiac event, please seek a professional medical opinion. Read my fascinating disclaimer page.
Q: Have you held back from speaking up because you were being “nice”?
WARNING: Take your blood pressure medication before you read Maya Dusenbery’s book: Doing Harm: The Truth About How Bad Medicine and Lazy Science Leave Women Dismissed, Misdiagnosed, and Sick.