It was 10 a.m. sharp when I walked into the gym where my cardiac rehabilitation classes were about to begin. The group’s coordinator was a friendly former cardiac nurse who now spent her mornings with freshly-diagnosed heart patients in the rehab program. She greeted me warmly, and toured me around the facility, introducing me to my fellow cardiac rehab buddies. And “fellow” was the apt word: it turned out that in that particular class, I was the only female heart patient in a gym filled with men. Old men. Old men who all happened to be golfers – which I would soon learn was the sole topic of their conversations. My initial reaction was: “Do I belong here?” . .
I noticed while we were introducing ourselves that I was the only participant who had had a heart attack. My buddies, by comparison, had all had open heart surgery (either heart valve replacements or double, triple and even quadruple bypass operations ). Each had called their family doctor after strange symptoms struck, tests swiftly ordered, revealing the need for that trip to the O.R. – likely preventing a heart attack. Many of the men offered generously to lift their T-shirts to show off their impressive surgical scars to me. One triple bypass veteran dramatically described his surgery as “having your whole chest cracked open like a turkey carcass!“
I also noticed that I was by far the youngest person in the room, by easily two decades.
And I was the only person there who was still working. Everyone else had retired from the workforce many years before their cardiac surgeries triggered a referral to rehab. But I was back at work at my public relations post on a half-day return-to-work trial after my own heart attack. Cardiac rehabilitation was something I’d learned could help to prevent another heart attack down the road. And I’d also learned that women are far more likely than men to be cardiac rehab dropouts. I was NOT going to be one of them! Having a heart attack in my 50s had been a catastrophic shock for me, and I was determined to do whatever it took to complete our full 3-month, twice-weekly program.
My new rehab buddies turned out to be a jolly bunch. Their first question to me wasn’t about my own diagnosis, but this: “Carolyn, are you a golfer?” (Sadly, no – except for two corporate fundraising events many years earlier which convinced me that the pursuit of activities I’m that awful at doing is not good for my self-esteem).
I also noticed that most of my buddies were not that interested in exerting themselves. Two of them, for example, seemed to spend the entire 90-minute class strolling s-l-o-w-l-y on their treadmills, while chatting about their last golf game, or their upcoming golf game, or favourite courses they’d played over the years while spending winters down in Arizona. While I silently did my prescribed warm-ups, cardio, cool-downs and carefully counted reps on the weight-training circuit, most of my rehab buddies seemed happiest leaning against the StairMaster and chatting, interrupted only occasionally by the encouraging reminders of our coordinator to actually try getting ON the StairMaster. One morning, I teased them that all they needed were a few glasses of Scotch to look like they were enjoying themselves down at the Union Club.
Once again, I couldn’t help but look around at my laid-back golfers each week and wonder: “Do I belong here?”
Whenever I read about women’s known track record of dropping out of their cardiac rehabilitation programs, I feel terrible for them. And yet, hardly surprised.
Cardiac rehab hours have primarily been set for the convenience of program staff, not heart patients – especially if those patients are women with jobs outside the home. Even pre-COVID, there were no evening, after-work or weekend hours of cardiac rehab classes available where I live. There was no child care or travel assistance provided. And absolutely no program funding to help pay hundreds of dollars up front for these classes. See also: Why Aren’t Female Heart Patients Showing Up for Cardiac Rehab?
Even here in Canada (our beautiful “commie pinko land of socialized medicine”), our government paid every penny of my Emergency Department visits, all diagnostic tests, all drugs, all cardiac procedures including two separate trips to the cath lab, all medical and nursing care in the CCU, my hospital bed and follow-up consultations with a cardiologist (for life!) – but they won’t fund a cardiologist-prescribed rehab program that has been shown to accomplish the following:
- lower our risks of death or heart attack by a whopping 25-40 per cent (that’s better than statins, by the way)
- reduce angina symptoms
- increase functional capacity
- improve lipid (cholesterol) levels
- reduce smoking by 25 per cent
- enhance psychological well-being
- improve exercise tolerance for all – including the elderly, frail or those with heart failure
Cardiac rehabilitation really works. And because many studies continue to confirm its proven benefits, cardiac rehab is in fact listed by all international cardiology societies as a Class I therapeutic intervention, meaning that all eligible heart patients worldwide should be referred. Should be – but physician referral rates are generally dismal. (And by the way, clicking a tickbox on a computer screen is NOT a referral if the physician has not spoken with a patient first about rehab). See also: Failure to Refer: Why Are Doctors Ignoring Cardiac Rehab?
But pandemic restrictions have meant that in-person cardiac rehabilitation classes like ours were temporarily no longer possible. Instead, online programs have emerged, and these may in fact evolve into a long-lasting tele-health alternative, post-COVID. Cardiac researchers like Dr. Scott Lear at Simon Fraser University have lobbied for years for “the development of virtual cardiac rehabilitation programs that can be remotely conducted, reaching patients in their homes and communities. These programs use a range of accessible technologies such as telephone, internet, text messaging, and smartphones.”(1)
“Do I belong here?” It’s an ironic question, really. It’s almost as if cardiac rehab programs have been set up by people trying to deliberately dissuade some heart patients from participating. The opportunity to fast-track other options that will attract more heart patients is upon us.
It’s important for hospitals and other cardiac organizations to acknowledge that there are at least two unique types of preventable obstacles that patients face in participating in this or any other type of post-diagnosis ongoing support program:
1. The first is a passive “You don’t belong here” message (like my cardiac rehabilitation program which, because of how the program is structured – for example, weekday-only hours – is geared to appeal to only a specific type of participant). They don’t actively refuse to sign up younger or working or female non-golfers, but they also don’t seem to examine their own demographics to even notice what kind of patients are missing. And we already know that men are far more likely to be referred to cardiac rehab by their cardiologists compared to women. In short, most cardiac rehabilitation classes are designed for old retired men who can afford winters in Arizona. We might as well hang up a shingle that reads “Retired Old Golfers Only Need Apply”.
2. The second is a more overt “You don’t belong here” message in which organizers deliberately bar the door to some (but not all) diagnosed patients. This seems impossible to even imagine, but consider this example shared by Abigail Johnston, a woman who has been living with Stage IV metastatic breast cancer since 2017:
“My first introduction to the division between metastatic breast cancer patients and those with early stage breast cancer was when I was asked by a social worker NOT to come to the regular breast cancer support group. Her explanation as to why I shouldn’t attend was that I might scare the other early stage participants.”
That’s like telling me that if I meet old retired golfers at cardiac rehab who insist on lifting their T-shirts to show off their triple bypass surgical scars to me, I’ll be scared off. (Well, after the first two or three, they’re actually not that scary).
But the reality is that if a passive barrier exists, organizers are by default endorsing a form of overt barrier.
Personally, I was able, through sheer stubbornness – despite all of those “Do I belong here?” questions – to hang in, week after week, until I ‘graduated’ from my rehab program and hugged my golfing rehab buddies goodbye. By then, I felt better, I looked better, I slept better – I can’t say enough about what cardiac rehabilitation did for my own recuperation – both physically and (even more critically important) psychologically.
We all know how reassuring it can feel to be genuinely welcomed into any type of group, as sociologist Dr. Tracy Brower, author of The Secrets to Happiness at Work, explains:
“Belonging is more than just about having friends, and the pandemic has brought belonging into sharpened focus. Belonging is good for our wellbeing as humans. And when we identify with groups of humans, it can provide a lens through which we can see the world.”
Image: H. Braxmeier, Pixabay
Q: What more can support groups do to reassure participants that we DO belong there?
NOTE FROM CAROLYN: I wrote much more about why female heart patients should complete their cardiac rehabilitation programs in my book, A Woman’s Guide to Living with Heart Disease. You can ask for it at your local 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 JHUP code HTWN to save 20% off the list price).