This week, three books and three bold messages about the problem with male-centric medicine: In her book Sex Matters: How Male-Centric Medicine Endangers Women’s Health, Dr. Alyson McGregor defines male-centric medicine like this: medical research and medical practice based on models historically designed to work in men, while ignoring the unique biological/emotional differences between men and women. In fact, she writes that the male-centric model of medicine is now so pervasive in health care that many of us don’t even realize it exists:
“Women who experience severe pain often have trouble convincing the doctor treating them of how serious that pain is. The more women protest and try to convince the physician, the more their behaviour is perceived as hysterical. This perception can work against them in the Emergency Department.”
If that’s where you are, Dr. McGregor warns: “the best thing you can do as a woman is to bring a man with you to explain your symptoms.” .
Has it come to this? Do we really need to bring along a husband or brother or Dad if we want doctors to take our symptoms seriously? I had some pretty darned serious cardiac symptoms (central chest pain, nausea, profuse sweating and pain down my left arm) while an Emergency physician was busy misdiagnosing me with acid reflux during my widow maker heart attack. Maybe I should have dragged a man with me that morning to confirm that what I’d just told the Doc was indeed true.
Women’s misdiagnoses like mine are (among other fascinating facts) what Dr. Sian Harding also wrote about in her new book The Exquisite Machine: The New Science of the Heart, published last week by MIT Press. In a recent related article in The Guardian, Dr. Harding asks these questions:
“Why are women with heart disease more likely to be misdiagnosed than men, and have worse outcomes for surgery? What is behind this gender bias and how can it be fixed?”
A cardiology professor for over 40 years, Dr. Harding states: “As well as being misdiagnosed, women are less likely to be treated quickly, less likely to get the best surgical treatment and less likely to be discharged with the optimum set of drugs. None of this is excusable, but is it understandable?”
If this reality seems impossible to either understand or excuse, read: “Fewer lights/sirens when a woman heart attack patient is in the ambulance”
Here are the three most commonly heard physician excuses listed by Dr. Harding:
Excuse #1: Women don’t develop heart disease as much as men, and so seeing a woman with a heart attack is “unexpected”: Dr. Harding argues that, while it’s true that women themselves may not expect to have a heart attack, and so may overlook the first symptoms, she remains unconvinced by the justifications she often hears from her medical colleagues. About 21% of women die from heart disease – comparable to men at 24%. “For any physician, seeing a woman with heart disease cannot be called unexpected”.
Excuse #2: Women’s symptoms are strange and unpredictable. Dr. Harding addresses this excuse with another dose of reality: there is a great deal of overlap between the sexes in the cardiac symptoms they experience – including chest pain: “Feeling sick, sweaty, or lightheaded are also symptoms common to both, as is the classic symptom of crushing chest pain, often radiating up the arms and to the jaw. These heart attack symptoms are the most common symptoms in both men and women. There should be no excuse for remaining ignorant of this range of symptoms.”
Excuse #3: Established standards and treatment guidelines for all heart patients are already well defined for physicians. Dr. Harding believes that all doctors should be recognizing heart disease in women and providing the optimum standard of care. However, she warns: “This is not happening.” Clinicians, she explains, are less likely to stick to the guidelines when treating women patients, sending them home with painkillers rather than the cardiac medications they prescribe for men. “Women are offered appropriate interventions significantly less promptly than men, and this has contributed to the higher death rate”. Dr. Harding adds that for every 5-minute delay in appropriate cardiac treatment, there’s a 5% increase in the risk of death.
She also cites a number of published studies with consistently appalling conclusions if you’re a woman seeking cardiac care. One was a large study on physician gender and treatment outcomes in 1.3 million Florida residents admitted to hospital for heart attack. “Survival rates were two to three times higher for female patients treated by female physicians compared with female patients treated by male physicians.” And the number of female colleagues a male doctor works with can also make a difference in increased survival rates of female heart patients:
“A higher proportion of female doctors improved both the success of the team in general and the competence of the men on the team for treating women. The study concluded that the best way to help female patients was to have a gender-balanced team, rather than waiting for individual male doctors to gain experience at the expense of their early failures.”
Perhaps the most thought-provoking question that Dr. Harding asks was this one:
What is it about female heart patients that makes so many male doctors treat them differently? What behaviours or characteristics trigger this dismissive response in a male physician?
One factor, she believes, is the attributes of patients traditionally thought of as male or female – and importantly, which might be valued differently if displayed by a man or a woman. For example: “Are you shy, gentle and compassionate – or assertive, risk-taking and individualistic?” All these add up, she explains, to how male or female we may appear.
When gender and biological sex were compared for how they influenced treatment, it was the perceived gender – the strength of the “female” score compared with the “male” – that made the difference in treatment and outcome. For example, “female” patients (men or women) were four times more likely to need to return to the hospital with recurrent symptoms after being discharged:
“Essentially, behaving in a manner perceived as traditionally female downgrades you in the eyes of a male physician – there is a higher chance that your distress will be seen as overblown, inaccurate or hysterical.”
I’ve written about this concept while trying to make sense of why physicians so often respond dismissively to female heart patients. I wrote, for example, about Montréal researchers led by Dr. Louise Pilote at McGill University who offered up a similar explanation for what they described as this “significant gender bias against women with heart disease”:
“ Gender-related determinants included feminine traits of personality and responsibility for housework.”
Yes. Housework! Dr. Piolote’s research participants were surveyed about “feminine personality traits” (like being unassertive) and perceived social standing, as well as who in their household was responsible for housework. The researchers’ take on the results: these “feminine” personality traits and housework responsibilities (observed in both men and women in Emergency) are “associated with inferior cardiac care.”
Finally, in author Maya Dusenbery’s must-read book, Doing Harm: The Truth About How Bad Medicine and Lazy Science Leave Women Dismissed, Misdiagnosed, and Sick, she pleads with doctors:
“Believe women when we tell you we’re sick.”
Men rarely have to beg to be believed by their doctors. A Cornell University study for example, found that heart attack symptoms presented in the context of a recent stressful life event were identified by physicians as psychological in origin when presented by women, but cardiac in origin when presented by men.
These three authors are certainly not alone in their frustration. There are plenty of us who are beyond frustrated by now. Being dismissed, misdiagnosed and sent home will do that to you. . .
Q: Have you had the experience of doctors communicating to your male companion rather than you?
NOTE FROM CAROLYN: I wrote more about cardiology’s known gender gap in my book “A Woman’s Guide to Living with Heart Disease“. You can ask for it at bookstores (please support your local independent bookseller!) or order it online (paperback, hardcover or e-book) at Amazon – or order it directly from my publisher Johns Hopkins University Press (use their code HTWN to save 30% off the list price).